Post written by Maria Manuela Estevinho, MD, and Rolando Pinho, MD, from the Department of Gastroenterology, Vila Nova de Gaia Espinho Hospital Center, Vila Nova de Gaia, Portugal.

We report on a modified Zenker peroral endoscopic myotomy (Z-POEM) technique (tunneling-free) that was carried out on 4 patients.

Initially, a mucosal incision was made over the septum and along its axis using the Flush Knife BTS 1.5 mm (ENDO CUTQ; Fujifilm Medical Co, Tokyo, Japan) (effect 1, duration 3, interval 1, using the unit ERBE VIO300S [ERBE Elektromedizim, Tübingen, Germany]) after submucosal injection.

Subsequently, the submucosa directly over the muscular septum was dissected to access the cricopharyngeus, while the submucosa on both septum sides was merely injected. The complete septotomy, preserving the submucosa on the sides of the septum, was safely accomplished using the Flush Knife BTS under direct endoscopic visualization until all cricopharyngeal fibers were dissected.

Finally, the mucosal incision was closed using standard clips. The procedures were successful without adverse events, and the patients experienced complete resolution of their symptoms.

Showcasing this video is important because the tunneling-free approach appears to be faster than Z-POEM and peroral endoscopic septotomy (POES), with a significantly shorter intraprocedural time (mean duration of 9 minutes vs 30-40 minutes for other techniques). Considering this characteristic, we named the novel approach “readily POES” (R-POES).

Moreover, there is a plausible hypothesis that this tunneling-free approach offers enhanced safety compared with traditional methods that require tunneling. Indeed, submucosal tunneling can be challenging and may potentially lead to additional harm, particularly mucosa damage.

Our experience demonstrates that the tunneling-free approach to Zenker diverticulum is faster and safe. Further experiences and studies, ideally randomized controlled trials, will be valuable in clarifying its safety and short- and long-term efficacy.

In addition, there is a need to investigate whether combining the tunneling-free myotomy with mucosotomy is beneficial in preventing flap-related dysphagia, especially in patients with larger Zenker diverticulum, as well as in cases with limited working space.

Dissection of the submucosa above the septum.

Read the full article online.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.