Post written by Linda Yun Zhang, MBBS, FRACP, from the Department of Gastroenterology & Hepatology, St George Hospital, Sydney, New South Wales, Australia.
Flexible endoscopic cricopharyngeal myotomy allows minimally invasive treatment of patients with Zenker’s diverticulum. Despite its wide uptake there is a substantial retreatment rate, which is at least partly due to the lack of a good intraprocedural determinant of myotomy adequacy. In this study, we examine the safety and feasibility of the functional lumen imaging probe (FLIP) as an intraprocedural tool to guide depth of cricopharyngeal myotomy in patients with Zenker’s diverticulum.
Unlike in peroral endoscopic myotomy (POEM), the mucosa overlying the cricopharyngeal muscle is not preserved during flexible endoscopic cricopharyngeal myotomy. Thus, it can be challenging to balance the adequacy of myotomy against the risk of esophageal perforation and adventitial injury. FLIP has been shown to discriminate clinical response in patients with achalasia and pharyngo-esophageal strictures following treatment. This supports the notion that intraprocedural use of FLIP could address the technical challenges faced during flexible endoscopic cricopharyngeal myotomy for Zenker’s diverticulum. We therefore performed this study to address this.
In this study, we confirmed that poor cricopharyngeal compliance is the pathophysiological basis of Zenker’s diverticulum, a finding which has previously only been indirectly implied through videofluoroscopy and manometry. Further, we showed that this is at least partially reversible by flexible endoscopic cricopharyngeal myotomy. Most importantly, intra-procedural use of FLIP appeared to be highly sensitive in detecting within-subject changes in cricopharyngeal distensibility after cricopharyngeal myotomy, supporting FLIP’s role in the endoscopists’ armamentarium to optimize clinical outcomes after cricopharyngeal myotomy. Future studies should focus on defining validated threshold values to predict clinical outcome.
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