When Z-POEM comes to the rescue of classical diverticulotomy and vice versa

If the treatment of Zenkerʼs diverticulum by flexible endoscopy seems to be the preferred option for its efficacy and safety profile [1], the recent arrival of Z-POEM (peroral endoscopic myotomy) technique has blurred the cards a little. Indeed, although the results of the Z-POEM technique seem good [2] [3], no randomized comparative data is available to choose this technique over classical diverticulotomy. The theoretical advantage of classical diverticulotomy is that it cuts the mucosal relief and performs the cricopharyngeal myotomy without having a very clear marker to be certain of the completeness of the myotomy. On the other hand, Z-POEM offers the possibility to cut the muscle completely thanks to better visualization, with almost zero risk of perforation not covered by the tunnel.

However, these two techniques are not 100 % effective. Here we present two cases of clinical failure with recurrence of dysphagia after a Z-POEM and a diverticulotomy, respectively ([Video 1]). To treat these patients, we chose a cross-over by making a Z-POEM to cut the muscle more deeply in the patient who had had a classical diverticulotomy [4] ([Fig. 1]), and on the other hand, a classical diverticulotomy to cut the residual mucosal relief in the patient who had had a Z-POEM ([Fig. 2]). In both cases it was possible to remove the residual relief of the diverticulum and a notable clinical improvement was observed.

Video 1 When Z-POEM comes to the rescue of classical diverticulotomy and vice versa.

Fig. 1 A Z-POEM was performed to cut the muscle more deeply in a patient who had had a diverticulotomy.

Fig. 2 A diverticulotomy was performed to cut the residual mucosal relief in a patient who had had a Z-POEM.

These cases perhaps illustrate the complementarity of the two techniques and the possible need to combine them to cut the muscle more deeply thanks to Z-POEM while cutting the mucous relief at the end of the procedure so as not to leave residual mucous relief, which is a source of symptomatic recurrence.

Endoscopy_UCTN_Code_CPL_1AH_2AH

Publication History

Article published online:
12 May 2021

• References

• 1 Calavas L, Brenet E, Rivory J. et al. Zenker diverticulum treatment: retrospective comparison of flexible endoscopic window technique and surgical approaches. Surg Endosc 2020;
• 2 Hernández Mondragón OV, Solórzano Pineda MO, Blancas Valencia JM. Zenker’s diverticulum: Submucosal tunneling endoscopic septum division (Z-POEM). Dig Endosc 2018; 30: 124
• 3 Yang J, Zeng X, Yuan X. et al. An international study on the use of peroral endoscopic myotomy (POEM) in the management of esophageal diverticula: the first multicenter D-POEM experience. Endoscopy 2019; 51: 346-349
• 4 Sanaei O, Ichkhanian Y, Mondragón OVH. et al. Impact of prior treatment on feasibility and outcomes of Zenker’s peroral endoscopic myotomy (Z-POEM). Endoscopy 2020;