Post written by Kapil Sharma, DM, from the Department of Gastroenterology, Sarvodaya Hospital and Medical Research Centre, Faridabad, Haryana, India.

We describe a novel approach to managing a case of absolute dysphagia caused by a large Zenker’s diverticulum (ZD) in an elderly man. The procedure, termed open Zenker’s-peroral endoscopic myotomy (OZ-POEM), incorporates submucosal tunneling to conduct cricopharyngeal muscle and esophageal muscle myotomy, extending to the base of the ZD.

In addition, a unique mucosotomy was performed to mitigate recurrence because of the remnant mucosal flap, an aspect not previously reported with Zenker’s-peroral endoscopic myotomy (Z-POEM). The technique began with a direct mucosal injection and incision at the septum, facilitating submucosal entry.

After myotomy and mucosotomy, the procedure resulted in a visually evident improvement in the luminal diameter of the esophageal inlet. An immediate postprocedural esophagogram confirmed free passage of contrast into the esophagus without evidence of leakage. At follow-ups conducted 1 and 6 months postprocedure, the patient reported complete resolution of dysphagia, underscoring the success of this novel approach.

To our knowledge, this is the first instance when mucosotomy was incorporated into Z-POEM without closure of the mucosal flap. This innovation prevents recurrence caused by residual mucosal flaps and obviates the need for flap closure or clipping, which can sometimes be technically challenging.

This case demonstrates the feasibility of OZ-POEM in treating a large ZD. Endoscopists can learn the importance of additional mucosotomy apart from standard Z-POEM as a crucial step in preventing recurrence and improving procedural efficiency while treating a large ZD.

However, careful dissection is imperative, especially in the inferoposterior aspects of the ZD, where only the buccopharyngeal fascia provides additional safeguarding. Large-scale studies are warranted to evaluate the safety and efficacy of OZ-POEM.

Endoscopy shows esophageal inlet (blue arrow) is pushed anteriorly and appears indented by septum (black arrow) and Zenker’s diverticulum (yellow arrow) seen in line with the hypopharynx.

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