Long-term outcomes of Zenker’s peroral endoscopic myotomy (Z-POEM) for treatment of Zenker’s diverticulum

Abstract

Background and study aims Z-POEM is now an established therapy for symptomatic Zenker’s diverticulum (ZD). Short-term follow-up of up to 1-year post Z-POEM suggests excellent efficacy and safety; however, long-term outcomes are not known. Thus, we sought to report on longer-term outcomes (≥ 2 years) following Z-POEM for treatment of ZD.

Patients and methods This was an International multicenter retrospective study at eight institutions across North America, Europe, and Asia over a 5-year period (from December 3, 2015 to March 13, 2020) of patients who underwent Z-POEM for management of ZD with a minimum 2-year follow-up. The primary outcome was clinical success, defined as improvement in dysphagia score to ≤ 1 without need for further procedures during the first 6 months. Secondary outcomes included rate of recurrence in patients initially meeting clinical success, rate of reintervention, and adverse events (AEs).

Results A total of 89 patients (male 57.3 %, mean age 71 ± 12 years) underwent Z-POEM for treatment of ZD (mean diverticulum size was 3.4 ± 1.3 cm). Technical success was achieved in 97.8 % of patients (n = 87) with a mean procedure time of 43.8 ± 19.2 minutes. The median post-procedure hospital stay was 1 day. There were eight AEs (9 %) (3 mild, 5 moderate). Overall, clinical success was achieved in 84 patients (94 %). Mean dysphagia, regurgitation, and respiratory scores all improved dramatically from 2.1 ± 0.8, 2.8 ± 1.3, and 1.8 ± 1.6 pre-procedure to 0.13 ± 0.5, 0.11 ± 0.5, and 0.05 ± 0.4, respectively, post-procedure at most recent follow-up (all P < 0.0001). Recurrence occurred in six patients (6.7 %) during a mean length of follow-up of 37 months (range 24 to 63 months).

Conclusions Z-POEM is a highly safe and effective treatment for Zenker’s diverticulum with durable treatment effect to at least 2 years.

• References

• 1 Bizzotto A, Iacopini F, Landi R. et al. Zenkerʼs diverticulum: exploring treatment options. Acta Otorhinolaryngol Ital 2013; 33: 219-229
• 2 Yuan Y, Zhao YF, Hu Y. et al. Surgical treatment of Zenkerʼs diverticulum. Dig Surg 2013; 30: 207-218
• 3 Keck T, Rozsasi A, Grün PM. Surgical treatment of hypopharyngeal diverticulum (Zenkerʼs diverticulum). Eur Arch Otorhinolaryngol 2010; 267: 587-592
• 4 Case DJ, Baron TH. Flexible endoscopic management of Zenker diverticulum: the Mayo Clinic experience. Mayo Clin Proc 2010; 85: 719-722
• 5 Albers DV, Kondo A, Bernardo WM. et al. Endoscopic versus surgical approach in the treatment of Zenkerʼs diverticulum: systematic review and meta-analysis. Endosc Int Open 2016; 4: E678-E686
• 6 Calavas L, Brenet E, Rivory J. et al. Zenker diverticulum treatment: retrospective comparison of flexible endoscopic window technique and surgical approaches. Surg Endosc 2021; 35: 3744-3752
• 7 Ishaq S, Hassan C, Antonello A. et al. Flexible endoscopic treatment for Zenkerʼs diverticulum: a systematic review and meta-analysis. Gastrointest Endosc 2016; 83: 1076-1089.e1075
• 8 Inoue H, Minami H, Kobayashi Y. et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 2010; 42: 265-271
• 9 Brieau B, Leblanc S, Bordacahar B. et al. Submucosal tunneling endoscopic septum division for Zenkerʼs diverticulum: a reproducible procedure for endoscopists who perform peroral endoscopic myotomy. Endoscopy 2017; 49: 613-614
• 10 Al Ghamdi SS, Farha J, Moran RA. et al. Zenkerʼs peroral endoscopic myotomy, or flexible or rigid septotomy for Zenkerʼs diverticulum: a multicenter retrospective comparison. Endoscopy 2022; 54: 345-351
• 11 Elkholy S, El-Sherbiny M, Delano-Alonso R. et al. Peroral endoscopic myotomy as treatment for Zenkerʼs diverticulum (Z-POEM): a multi-center international study. Esophagus 2021; 18: 693-699
• 12 Balassone V, Pizzicannella M, Biasutto D. et al. Submucosal per-oral endoscopic myotomy for a large Zenkerʼs diverticulum with use of a hydrodissector knife and an over-the-scope clip closure. VideoGIE 2018; 3: 373-374
• 13 Hernández Mondragón OV, Solórzano Pineda MO, Blancas Valencia JM. Zenkerʼs diverticulum: Submucosal tunneling endoscopic septum division (Z-POEM). Dig Endosc 2018; 30: 124
• 14 Brewer Gutierrez OI, Ichkhanian Y, Spadaccini M. et al. Zenkerʼs diverticulum per-oral endoscopic myotomy techniques: changing paradigms. Gastroenterology 2019; 156: 2134-2135
• 15 Yang J, Novak S, Ujiki M. et al. An international study on the use of peroral endoscopic myotomy in the management of Zenkerʼs diverticulum. Gastrointest Endosc 2020; 91: 163-168
• 16 Dakkak M, Bennett JR. A new dysphagia score with objective validation. J Clin Gastroenterol 1992; 14: 99-100
• 17 Battaglia G, Antonello A, Realdon S. et al. Flexible endoscopic treatment for Zenkerʼs diverticulum with the SB Knife. Preliminary results from a single-center experience. Dig Endosc 2015; 27: 728-733
• 18 Zhang LY, Wu PI, Szczesniak M. et al. Clinical utility of cricopharyngeal distensibility measurements during endoscopic myotomy for Zenkerʼs diverticulum. Gastrointest Endosc 2021; 93: 390-397
• 19 Cotton PB, Eisen GM, Aabakken L. et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 2010; 71: 446-454
• 20 Halland M, Grooteman KV, Baron TH. Flexible endosopic management of Zenkerʼs diverticulum: characteristics and outcomes of 52 cases at a tertiary referral center. Dis Esophagus 2016; 29: 273-277
• 21 Verdonck J, Morton RP. Systematic review on treatment of Zenkerʼs diverticulum. Eur Arch Otorhinolaryngol 2015; 272: 3095-3107
• 22 Repici A. Endoscopic treatment of zenker diverticulum. Gastroenterol Hepatol (NY) 2010; 6: 628-630