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Modified Z-poem Technique For Zenkers Diverticulum: Perioperative And Intermediate Outcomes
Jennifer Risi, MD, Gursimran S. Kochhar, MD, Benny Weksler, MD, Lawrence Crist, DO, Mathew Van Deusen, MD, Kristy Rosenberry, RN, Hiran C. Fernando, MD.
Allegheny General Hospital, Pittsburgh, PA, USA.
BACKGROUND: The management of Zenker"s diverticulum (ZD) has evolved from an open operation, to rigid endoscopy and more recently to a flexible endoscopic approach (Z-POEM). Most centers reporting Z-POEM describe creation of a submucosal tunnel with saline injection around the cricopharyngeus muscle (CM), which is then divided with single-blade cautery. We report a modified technique, with no submucosal injection, and division of the CM using the Olympus SB knife, a scissor-type knife with insulated jaws. Our technique and outcomes are reported below
METHODS: We conducted a retrospective study of patients who underwent Z-POEM. . Procedure effectiveness was measured using dysphagia scores (scale 0=no dysphagia, 4=unable to swallow anything including saliva). Adverse events were analyzed and graded using the Clavien-Dindo classification. The operative technique involves visualizing the CM endoscopically, usually in a 12 to 6 o"clock position with the diverticulum on one side and the esophageal lumen on the other side of the CM . The mucosa is opened transversely over the CM. The SB knife is then used to grasp, pull then divide the CM away from the mucosa. After CM division, the mucosa is closed longitudinally with endo-clips.
RESULTS: A total of 26 patients, 53.8% male and 46.2% female, received Z-POEM. Mean age was 76 (46-94) years. Mean diverticulum size was 3.5 (2-8.1)cm, and mean BMI was 27(20-43). Median length of stay was 1 (1-13) days. Two patients had inpatient adverse events; one experienced atrial fibrillation and the second a grade 3 esophageal leak requiring reoperation. Two patients re-presented within 30 days with nausea (n=1) and pulmonary embolism (n=1). Nineteen patients had follow-up of 3 months or greater (mean 10.95; range 3-43 months). One patient required repeat Z-POEM for incomplete myotomy. Mean dysphagia score improved significantly at follow-up (pre-operative= 1.63 versus post-operative=0; p<0.001).
CONCLUSIONS: The modified Z-POEM technique is feasible, with only 1 grade 3 adverse event occurring in our series. Dysphagia scores were significantly improved at follow-up confirming the effectiveness of this approach.
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