PERORAL ENDOSCOPIC SEPTOTOMY (POES) FOR ZENKER DIVERTICULUM: A PILOT STUDY

Aims:

Treatments Zenker's diverticulum (ZD) aim to dissect the muscle in order to remove the underlying dysfunctional condition. In the last decade, the endoscopic septotomy performed with a flexible endoscope has been reported as a safe and effective alternative to both open surgery and rigid endoscopic diverticulotomy. More recently, Li described a novel endoscopic technique, called Z-POEM, inspired by the per-oral endoscopic myotomy (POEM) developed for Achalasia. Patients with short septum diverticulum represent a difficult-to-be-treated subgroup of patients because of anatomical limitation leading to reduced operation space. Aim of this study was to investigate the efficacy and safety of a novel alternative third space approach, called Per-Oral Endoscopic Septotomy (POES) to treat symptomatic patients with short-septumZD.

Methods:

All patients with short-septumZD who were referred for endoscopic repair since September2017, were considered for the study. Exclusion criteria consisted of previous treatments for Zenker, ZD with septum > 2 cm, use of anticoagulants, inability to provide informed consent. The POES technique consisted of a 15 mm mucosotomy performed, after submucosal injection, at the top of the diverticular septum, alongside its long axis. The underlying submucosa was dissected to create an endoscopic window to access the submucosal space and to visualize the muscular septum. Then this was dissected along its entire length, sparing the overlying mucosa. Mucosal incision was finally sealed with clips. Outcomes included improvement of dysphagic symptoms which were scored using the Dakkak and Bennett dysphagia scale (0 – 4) and procedure-related adverse events.

Results:

Fourteen patients (M/F:9/5, mean age:62.5 ± 13.2) underwent the POES. All procedures were performed under deep sedation. Mean size of ZD was18.1 ± 2.6 mm and mean dysphagia score was2.8 ± 0.4. Average procedural time was12.0 ± 2.6 min. No intra-nor post-procedural adverse events occurred. Septal miotomy was successfully completed in all patients. Procedure was performed in outpatient setting in11out14patients. Dysphagia has significantly improved in thirteen out of14 patients, with dysphagia score dropping from2.8 ± 0.4to0.2 ± 0.6. No recurrences were reported in a mean follow up time of7.3 ± 2.1months (range:6 – 12).

Conclusions:

According to the preliminary results of this pilot study, POES treatment provided safe and effective treatment of a specific difficult-to-treat group of patients with ZD.