Zenker′s diverticulum. Submucosal tunneling endoscopic septum division. (Z-POEM)

Abstract

Background

Zenker diverticulum is characterized by dysphagia, weight loss and bronchoaspiration [1]. Open surgery has been the cornerstone of treatment, with good response but recurrence up to 35%.[2]. Rigid endoscopic diverticulotomy has similar results, but with conversion to open surgery up to 30%[3]. Flexible endoscopic diverticulotomy is safe, effective and can be performed in an endoscopic setting, but multiple sessions are needed because of uncomplete cut of the septum[4,5]. Z-POEM is a new procedure in which a total septum myotomy throughout a submucosal tunnel can be performed. We describe this technique in an 85 years-old-male with big size zenker′s diverticulum.

Methods

After confirmation of a 35mm Zenker′s diverticulum, we performed procedure using an electrosurgical unit ERBE model VIO-200D, a regular endoscope coupled with a homemade cap and a CO2 insufflator. Flush knife model DK2618J(Fujinon, Japan), a sclerotherapy needle(Boston Scientific, USA), and resolution clips(Boston Scientific, USA).

Technique: First: creation of a submucosal bleb 3cms above the septum with a 10mm longitudinal incision. Second: submucosal tunnel was created up to the diverticular septum. Third, total myotomy of the septum and fourth, a mucosal closure was performed with 5 clips. Characteristics of procedure were documented.

Results

Z-POEM was performed successfully without adverse events during or after procediure. Barium esophagram test showed a decrease of more than 80% of the original diverticular size (6mm), and no bronchoaspiration signs were observed. The patient was discharged at 48hrs after Z-POEM and at 1 month after, no dysphagia was observed and patient can eat a normal diet.

Conclusions

Z-POEM or so called submucosal tunneling endoscopic septum division technique is a safe and effective procedure for the treatment of Zenker′s diverticulum with the advantages of a complete septum division, faster recovery and that can be performed in patients with different diverticular sizes an even with high comorbidities.

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