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Sheridan B, Dinh T, Hendrick LE, Moran L, Zhao J, Leesley H, Ng T. Critical Analysis of Outcomes After Surgical Management of Zenker's Diverticulum. J Gastrointest Surg 2024:S1091-255X(24)00588-2. [PMID: 39179020 DOI: 10.1016/j.gassur.2024.08.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 04/28/2024] [Accepted: 08/18/2024] [Indexed: 08/26/2024]
Affiliation(s)
- Brenden Sheridan
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Theresa Dinh
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Leah E Hendrick
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Lindsey Moran
- Department of Surgery, Alpert Medical School of Brown University, Providence, RI
| | - Jane Zhao
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN; Division of Thoracic Surgery, University of Tennessee Health Science Center, Memphis, TN
| | - Haley Leesley
- Department of Surgery, Alpert Medical School of Brown University, Providence, RI
| | - Thomas Ng
- Department of Surgery, University of Tennessee Health Science Center, Memphis, TN; Division of Thoracic Surgery, University of Tennessee Health Science Center, Memphis, TN.
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Norton B, Siggens K, Papaefthymiou A, Telese A, Duku M, Murino A, Johnson G, Murray C, Mohammadi B, Mughal M, Bisschops R, Bhandari P, Birchall M, Haidry R. The safety and efficacy of endoscopic approaches for the management of Zenker's diverticulum: a multicentre retrospective study. Surg Endosc 2024:10.1007/s00464-024-11164-4. [PMID: 39160304 DOI: 10.1007/s00464-024-11164-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 08/05/2024] [Indexed: 08/21/2024]
Abstract
INTRODUCTION Minimally invasive endoscopic options are safe and effective alternatives to surgery for the treatment of symptomatic Zenker's diverticulum (ZD). However, there is no consensus on the gold-standard approach. We compared the safety and efficacy of Zenker's peroral endoscopic myotomy (Z-POEM), flexible diverticulotomy (FD), and rigid diverticulotomy (RD) for the management of ZD. METHODS Patients undergoing treatment for ZD at three UK tertiary referral centres were identified and analysed between 2013 and 2023. Patient demographics, procedural details, clinical success, and 30-day adverse events (AE) were recorded. The primary outcomes were technical and clinical success defined as a fall in Dakkak and Bennett dysphagia score to ≤ 1 without re-intervention. RESULTS There was no difference in baseline characteristics amongst 126 patients undergoing intervention (50 RD, 31 FD, 45 Z-POEM). Technical success for RD, FD, and Z-POEM was 80%, 100%, and 100%, respectively (p < 0.001). Over a mean follow-up of 11.0 months (95% CI 8.2-13.9), clinical success amongst those treated was 85.3% (RD), 74.1% (FD), and 83.7% (Z-POEM; p = 0.48) with recurrence in 17.2% (RD), 20.0% (FD), and 8.3% (Z-POEM; p = 0.50). AEs were equivalent between groups (p = 0.98). During this time, 11 patients underwent surgical myotomy with low clinical success (36.4%) and high morbidity. CONCLUSION Endoscopic options for the treatment of ZD show equivalent rates of success, but failed RD often led to open myotomy with worse outcomes. Flexible endoscopic modalities are both safe and highly effective treatments that may be considered first-line in experienced centres and should be offered before surgery.
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Affiliation(s)
- Benjamin Norton
- Digestive Diseases & Surgical Institute, Cleveland Clinic London, London, UK.
- Department of Gastroenterology, University College London Hospital, Euston Road, London, NW1 2BU, UK.
- Centre for Obesity Research, University College London, London, UK.
| | - Katie Siggens
- Department of Gastroenterology, Portsmouth University Hospitals, Portsmouth, UK
| | | | - Andrea Telese
- Digestive Diseases & Surgical Institute, Cleveland Clinic London, London, UK
- Division of Surgery and Interventional Science, University College London, London, UK
| | - Margaret Duku
- Digestive Diseases & Surgical Institute, Cleveland Clinic London, London, UK
| | - Alberto Murino
- Digestive Diseases & Surgical Institute, Cleveland Clinic London, London, UK
| | - Gavin Johnson
- Digestive Diseases & Surgical Institute, Cleveland Clinic London, London, UK
| | - Charles Murray
- Digestive Diseases & Surgical Institute, Cleveland Clinic London, London, UK
| | - Borzoueh Mohammadi
- Digestive Diseases & Surgical Institute, Cleveland Clinic London, London, UK
| | - Muntzer Mughal
- Digestive Diseases & Surgical Institute, Cleveland Clinic London, London, UK
| | - Raf Bisschops
- Department of Gastroenterology and Hepatology, UZ Leuven. TARGID, Louvain, KU, Belgium
| | - Pradeep Bhandari
- Department of Gastroenterology, Portsmouth University Hospitals, Portsmouth, UK
| | - Martin Birchall
- Royal National Ear Nose and Throat and Eastman Dental Hospitals, University College London Hospital, London, UK
- The Ear Institute University College London, London, UK
| | - Rehan Haidry
- Digestive Diseases & Surgical Institute, Cleveland Clinic London, London, UK
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Tie K, Manayan RC, Mallur PS. 445nm Blue Laser for Cricopharyngeal Myotomy/Zenker's Diverticulotomy: Proof of Concept and Use. Laryngoscope 2024. [PMID: 38994882 DOI: 10.1002/lary.31632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 06/08/2024] [Accepted: 06/26/2024] [Indexed: 07/13/2024]
Abstract
OBJECTIVE(S) Treatment for Zenker's diverticulum and cricopharyngeal dysfunction has evolved to include flexible endoscopic approaches. Currently, no flexible modalities combine the precision cutting of CO2 laser and the hemostasis of knife electrocautery. We present the first series describing fiber-based 445nm blue light (BL) laser for endoscopic cricopharyngeal myotomy/Zenker's diverticulotomy. We describe usage characteristics and laser parameters with rigid esophagoscopy to determine the feasibility of use with flexible endoscopy. METHODS Retrospective review and literature review. RESULTS The first nine cases of endoscopic diverticulotomy (n = 5) and cricopharyngeal myotomy (n = 4) with BL were reviewed. Rigid exposure was achieved with the Dohlman Slimline diverticuloscope. Mean age was 75.6 years. Average diverticulum depth was 0.89 cm ±1.0 cm. Pulsed mode was used in seven cases with mean of 6.86 W, 54 ms pulse on, and 286 ms pulse pause and overall mean of 6.00 W and 405 J. Complete myotomy with intact buccopharyngeal fascia and without bleeding limiting view was achieved in all patients. One of two patients in whom continuous wave setting was used developed subcutaneous emphysema following vigorous cough on POD0; this resolved after 7 days nothing per oral (NPO). Eight patients were started on oral intake without evidence for leak. Pulsed mode with fiber-to-tissue contact provided effective muscle cutting without disruption of buccopharyngeal fascia. Literature review yielded three articles examining flexible approach with laser for Zenker's and none with BL. CONCLUSION BL provides safe and effective fiber-based cutting and hemostasis in endoscopic cricopharyngeal myotomy/Zenker's diverticulotomy. Future use in flexible endoscopic approaches appears feasible, though continuous wave should be avoided. LEVEL OF EVIDENCE IV Laryngoscope, 2024.
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Affiliation(s)
- Kevin Tie
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, U.S.A
- Division of Otolaryngology, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, U.S.A
| | - Regan C Manayan
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, U.S.A
- Division of Otolaryngology, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, U.S.A
| | - Pavan S Mallur
- Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School, Boston, Massachusetts, U.S.A
- Division of Otolaryngology, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, U.S.A
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Dahiya DS, Deliwala S, Chandan S, Ramai D, Ali H, Kassab LL, Facciorusso A, Kochhar GS. Effectiveness and safety of stag beetle knife (SB knife) in management of Zenker's diverticulum: a systematic review and meta-analysis. Dis Esophagus 2024; 37:doad069. [PMID: 38100729 DOI: 10.1093/dote/doad069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 11/24/2023] [Indexed: 12/17/2023]
Abstract
Stag Beetle Knife (SB Knife) is increasingly being utilized for Zenker's Diverticulectomy (ZD). Our study assessed the effectiveness and safety of the SB Knife for the management of ZD. Ovid EBM reviews, Ovid Embase, Ovid Medline, ClinicalTrials.gov, Scopus, and Web of Science were searched to identify studies that utilized SB knife for ZD. Pooled proportions (PP) were calculated using the random-effects model. Heterogeneity was evaluated using I2 statistics. A total of 7 studies with 268 patients were included in the final analysis. Dysphagia and regurgitation were the most common clinical symptoms. The mean size of the ZD was 2.8 ± 0.7 cm and 28 (of 148) patients had undergone previous treatments. The PP of technical success was 98% (95% CI: 92.3-99.5; I20) with a mean procedure duration of 26.2 ± 8.3 minutes. The PP of clinical response at first follow-up and relapse after index procedure was 87.9% (95% CI: 81.6-92.3; I219) and 13.5% (95% CI: 9.6-18.6; I22), respectively. At final follow-up, the PP of clinical remission was 96.2% (95% CI: 91-98.4; I230.6) while the PP of procedure failure was 3.6% (95% CI: 1.6-8.1; I20). No severe adverse events (AEs) were noted while using the SB Knife. However, the PP of intraprocedural and postprocedural AEs was 13.2% (95% CI: 9.6-17.8; I20) and 9.3% (95% CI: 5.7-14.9; I2 < 20.9), respectively. SB Knife is highly safe and effective for Zenker's Diverticulectomy with a failure rate of only 3.6%.
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Affiliation(s)
- Dushyant Singh Dahiya
- Division of Gastroenterology, Hepatology & Motility, The University of Kansas School of Medicine, Kansas City, KS, USA
| | - Smit Deliwala
- Division of Digestive Diseases, Emory University School of Medicine, Atlanta, GA, USA
| | - Saurabh Chandan
- Division of Gastroenterology & Hepatology, CHI Creighton University Medical Center, Omaha, NE, USA
| | - Daryl Ramai
- Department of Gastroenterology, University of Utah, Salt Lake City, UT, USA
| | - Hassam Ali
- Division of Gastroenterology and Hepatology, East Carolina University/Brody School of Medicine, Greenville, NC, USA
| | - Lena L Kassab
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Antonio Facciorusso
- Gastroenterology Unit, Department of Surgical and Medical Sciences, University of Foggia, Foggia, Italy
| | - Gursimran S Kochhar
- Division of Gastroenterology, Hepatology & Nutrition, Allegheny Health Network, Pittsburgh, PA, USA
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Ren L, Ye H, Zhu Y, Xie W, Liang Y, Liu Y, Dong J, Chen W, Chen X, Wang B, Pan L, Shi R. Diverticular peroral endoscopic myotomy (D-POEM) for symptomatic oesophageal diverticulum: a multicentre cohort study with a minimum follow-up of 3 years. Surg Endosc 2024; 38:253-259. [PMID: 37985492 DOI: 10.1007/s00464-023-10471-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 09/13/2023] [Indexed: 11/22/2023]
Abstract
OBJECTIVE To evaluate the medium- and long-term outcomes of diverticular peroral endoscopic myotomy (D-POEM) for symptomatic oesophageal diverticulum. METHODS Consecutive patients with symptomatic oesophageal diverticulum who underwent D-POEM from 1st May 2016 to 1st April 2020 in 6 centres were extracted and researched. Symptoms assessed by the modified Eckardt score were registered pre- and post-D-POEM at 1, 6, 12, 24 and 36 months. RESULTS A total of 34 patients with Zenker's diverticulum (ZD, n = 12), mid-oesophageal diverticulum (MED, n = 12), and epiphrenic diverticulum (ED, n = 10) were included. Complete septotomy was achieved in a mean of 39.15 min, with 100% technical success. No severe intraoperative or postoperative complications were observed. Five patients exhibited subcutaneous emphysema, while 1 had mucosal injury. The mean Eckardt score was 8.59 preoperatively and 2.56 at 1 month, 2.09 at 6 months, 2.21 at 12 months, 2.15 at 24 months, and 2.21 at 36 months postoperatively. The total clinical success rates at 1, 6, 12, 24 and 36 months postoperatively were 97.1%, 97.1%, 94.1%, 91.2%, and 88.2%, respectively. With a median follow-up of 47.2 months, four patients suffered symptom relapse, with a total clinical success rate of 88.2%. A long disease duration, a high Eckardt score, and coexistence of achalasia were identified as risk factors for symptomatic recurrence by multivariable Cox analysis. CONCLUSIONS D-POEM is an effective and durable treatment for patients with symptomatic oesophageal diverticulum.
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Affiliation(s)
- Lihua Ren
- Department of Gastroenterology, Zhongda Hospital, School of Medicine, Southeast University, 87 Dingjiaqiao Road, Nanjing, 210009, Jiangsu Province, People's Republic of China
| | - Hui Ye
- Department of Gastroenterology, Zhongda Hospital, School of Medicine, Southeast University, 87 Dingjiaqiao Road, Nanjing, 210009, Jiangsu Province, People's Republic of China
| | - Ye Zhu
- Department of Gastroenterology, Zhongda Hospital, School of Medicine, Southeast University, 87 Dingjiaqiao Road, Nanjing, 210009, Jiangsu Province, People's Republic of China
| | - Weihua Xie
- Department of Quality Management, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, 325000, People's Republic of China
| | - Yan Liang
- Department of Gastroenterology, Zhongda Hospital, School of Medicine, Southeast University, 87 Dingjiaqiao Road, Nanjing, 210009, Jiangsu Province, People's Republic of China
| | - Yang Liu
- Department of Gastroenterology, Zhongda Hospital, School of Medicine, Southeast University, 87 Dingjiaqiao Road, Nanjing, 210009, Jiangsu Province, People's Republic of China
| | - Jingwu Dong
- Department of Gastroenterology, Xuyi County Peoples' Hospital, Huaian, 211700, People's Republic of China
| | - Weixu Chen
- Department of Gastroenterology, Xuzhou Central Hospital, Xuzhou, 221009, People's Republic of China
| | - Xinfu Chen
- Department of Gastroenterology, Xuzhou First People's Hospital, Xuzhou, 221000, People's Republic of China
| | - Bin Wang
- Department of Gastroenterology, Changshu No. 1 People's Hospital, Suzhou, 215500, People's Republic of China
| | - Liang Pan
- Department of Gastroenterology, Changzhou Jintan First People's Hospital, Changzhou, 213200, People's Republic of China
| | - Ruihua Shi
- Department of Gastroenterology, Zhongda Hospital, School of Medicine, Southeast University, 87 Dingjiaqiao Road, Nanjing, 210009, Jiangsu Province, People's Republic of China.
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Søfteland EØ, Aasebøstøl AK, Johnsen G, Bringeland EA. Endoluminal treatment for Zenker's diverticulum - a population-based observational study. Scand J Gastroenterol 2024; 59:218-224. [PMID: 37728323 DOI: 10.1080/00365521.2023.2260036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 09/12/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Zenker's diverticulum is a false diverticulum arising in the oesophago-pharyngeal junction. It may cause symptoms like dysphagia and regurgitation. In Central Norway, treatment is centralized to St. Olavs hospital, either as an endoscopic stapled oesophago-diverticulostomy procedure at the Department of Gastrointestinal Surgery or as laser diverticulostomy at the Department of Ear, Nose and Throat Surgery, depending on diverticulum size. METHODS Retrospective, population-based, study from 2001-2020 on patients treated for Zenker's diverticulum, at the time with a rigid endoscopic approach. Patients were identified through the in-hospital register for operations. The two treatment groups were compared on relevant pre-, intra-, and postoperative variables by review of the individual patient records. RESULTS 78 consecutive patients, 36 at Dept. of Ear, Nose and Throat Surgery and 42 at Dept. of Gastrointestinal Surgery, were treated with a total of 104 interventions. Crude incidence for a surgery-demanding Zenker's diverticulum was 0.57 per 100 000 per year. The Dept. of Ear, Nose and Throat Surgery administered significantly less often prophylactic antibiotics than the Dept. of Gastrointestinal Surgery (p < 0.001), administered more frequently intraoperative dexamethasone (p < 0.001), and had significantly more postoperative infections (19.6% vs 3.4%, p = 0.01). No procedure-related mortality was registered. Although no standardized follow-up took place, at a median of 119 months elapsed, observed clinical recurrence was 35% for the endostapler treatment and 51% for the laser treatment procedure. CONCLUSION Both rigid endoscopic stapled oesophago-diverticulostomy and laser diverticulostomy are safe treatments for Zenker's diverticulum, however with a substantial risk of recurrence.
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Affiliation(s)
- Eirik Østensen Søfteland
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Anne Kristin Aasebøstøl
- Department of Ear, Nose and Throat Surgery, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway
| | - Gjermund Johnsen
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Department of Gastrointestinal Surgery, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway
| | - Erling Audun Bringeland
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Department of Gastrointestinal Surgery, St. Olavs hospital, Trondheim University Hospital, Trondheim, Norway
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Starkov YG, Vagapov AI, Badakhova AB, Zamolodchikov RD, Dzhantukhanova SV. [Endoscopic treatment of recurrent Zenker diverticulum and postoperative esophageal stricture]. Khirurgiia (Mosk) 2024:70-75. [PMID: 38477246 DOI: 10.17116/hirurgia202403170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2024]
Abstract
Zenker diverticulum is a rare disease accounting for 1.5-5% of esophageal diverticula. For a long time, surgical treatment of Zenker pharyngoesophageal diverticula implied open diverticulectomy via cervical approach. However, this intervention is characterized by high postoperative morbidity and recurrence rate. Oral endoscopic minimally invasive cricopharyngoesophagomyotomy has become widespread over the past 10 years. We present a 55-year-old female who underwent endoscopic treatment for recurrent Zenker diverticulum and postoperative esophageal stricture. We obtained favorable result in a patient with recurrent Zenker diverticulum after previous open surgeries complicated by esophageal stricture. Endoscopic management eliminated recurrent diverticulum and esophageal stricture, as well as improved the quality of life. Endoscopic approach is preferable for pharynoesophageal diverticula compared to traditional surgical diverticulectomy. Obvious advantages of this technique are stable functional result, low incidence of complications and mortality, short-term postoperative period with fast rehabilitation. Extended myotomy is essential for successful oral endoscopic cricopharyngoesophagomyotomy.
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Affiliation(s)
- Yu G Starkov
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - A I Vagapov
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - A B Badakhova
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
| | - R D Zamolodchikov
- Vishnevsky National Medical Research Center of Surgery, Moscow, Russia
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Mandarino FV, Vespa E, Barchi A, Fasulo E, Sinagra E, Azzolini F, Danese S. Precision Endoscopy in Peroral Myotomies for Motility Disorders of the Upper Gastrointestinal Tract: Current Insights and Prospective Avenues-A Comprehensive Review. Life (Basel) 2023; 13:2143. [PMID: 38004283 PMCID: PMC10672509 DOI: 10.3390/life13112143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 10/28/2023] [Accepted: 10/29/2023] [Indexed: 11/26/2023] Open
Abstract
Our review delves into the realm of peroral endoscopic myotomies (POEMs) in the upper gastrointestinal tract (UGT). In recent years, POEMs have brought about a revolution in the treatment of UGT motility disorders. Esophageal POEM, the first to be introduced, has now been validated as the primary treatment for achalasia. Subsequently developed, G-POEM displays promising results in addressing refractory gastroparesis. Over time, multiple endoscopic myotomy techniques have emerged for the treatment of Zenker's diverticulum, including Z-POEM, POES, and hybrid approaches. Despite the well-established efficacy outcomes, new challenges arise in the realm of POEMs in the UGT. For esophageal POEM, the future scenario lies in customizing the myotomy extent to the minimum necessary, while for G-POEM, it involves identifying patients who can optimally benefit from the treatment. For ZD, it is crucial to validate an algorithm that considers various myotomy options according to the diverticulum's size and in relation to individual patients. These challenges align with the concept of precision endoscopy, personalizing the technique for each subject. Within our text, we comprehensively examine each myotomy technique, analyzing indications, outcomes, and adverse events. Additionally, we explore the emerging challenges posed by myotomies within the context of the evolving field of precision endoscopy.
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Affiliation(s)
- Francesco Vito Mandarino
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Edoardo Vespa
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Alberto Barchi
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Ernesto Fasulo
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Emanuele Sinagra
- Gastroenterology and Endoscopy Unit, Fondazione Istituto San Raffaele Giglio, 90015 Cefalù, Italy
| | - Francesco Azzolini
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
| | - Silvio Danese
- Department of Gastroenterology and Gastrointestinal Endoscopy, IRCCS San Raffaele Hospital, Vita-Salute San Raffaele University, Scientific Institute San Raffaele, 20132 Milan, Italy
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Wallerius KP, Bowen AJ, O'Byrne TJ, Aden AA, Peraza LR, Xie KZ, Richards BA, El-Badaoui J, Bayan SL, Wong Kee Song LM, Ekbom DC. Comparing Open Versus Rigid Endoscopic and Flexible Endoscopic Techniques for the Treatment of Zenker's Diverticulum. Otolaryngol Head Neck Surg 2023; 169:962-970. [PMID: 36906817 DOI: 10.1002/ohn.318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 01/16/2023] [Accepted: 01/27/2023] [Indexed: 03/13/2023]
Abstract
OBJECTIVE To describe the outcomes of patients undergoing open stapler versus transoral rigid and flexible endoscopic therapies for symptomatic Zenker's diverticulum. STUDY DESIGN Single institution retrospective review. SETTING Tertiary care academic hospital. METHODS We retrospectively evaluated the outcomes of 424 consecutive patients who underwent Zenker's diverticulotomy via an open stapler, rigid endoscopic CO2 laser, rigid endoscopic stapler, rigid endoscopic harmonic scalpel, or flexible endoscopic technique from January 2006 to December 2020. RESULTS A total of 424 patients (173 females, mean age 73.1 ± 11.2 years) from a single institution were included. A total of 142 patients (33%) underwent endoscopic laser treatment, 33 (8%) underwent endoscopic harmonic scalpel, 92 (22%) underwent endoscopic stapler, 70 (17%) underwent flexible endoscopic, and 87 (20%) underwent open stapler. All open and rigid endoscopic procedures and most of the flexible endoscopic procedures (65%) were performed under general anesthesia. The flexible endoscopic group had a higher percentage of procedure-related perforation, defined as subcutaneous emphysema or contrast leak on imaging (14.3%). The recurrence rates were higher in the harmonic stapler, flexible endoscopic, and endoscopic stapler groups at 18.2%, 17.1%, and 17.4%, respectively, and lower in the open group (1.1%). Length of hospital stay and return to oral intake were similar among groups. CONCLUSION The flexible endoscopic technique was associated with the highest rate of procedure-related perforation, while the endoscopic stapler had the lowest number of procedural complications. Recurrence rates were higher among the harmonic stapler, flexible endoscopic, and endoscopic stapler groups and lower in the endoscopic laser and open groups. Prospective comparative studies with long-term follow-up are needed.
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Affiliation(s)
- Katherine P Wallerius
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew J Bowen
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Thomas J O'Byrne
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Aisha A Aden
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Lazaro R Peraza
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Katherine Z Xie
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Bradley A Richards
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Joseph El-Badaoui
- Department of Surgery, University of Maryland, Baltimore, Maryland, USA
| | - Semirra L Bayan
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Dale C Ekbom
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Swei E, Pokala SK, Menard-Katcher P, Wagh MS. Comparison of Zenker's per-oral endoscopic myotomy (Z-POEM) with standard flexible endoscopic septotomy for Zenker's diverticulum: a prospective study with 2-year follow-up. Surg Endosc 2023; 37:6818-6823. [PMID: 37277515 PMCID: PMC10241386 DOI: 10.1007/s00464-023-10136-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 05/09/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND Flexible endoscopic therapy of Zenker's diverticulum using submucosal tunneling (Z-POEM) similar to esophageal Per-Oral Endoscopic Myotomy (POEM) is becoming increasingly common. However, data comparing Z-POEM with traditional flexible endoscopic septotomy (FES) are sparse. The aim of this study was to compare outcomes of Z-POEM with traditional FES over a medium-term follow-up period. METHODS This was a prospective study of patients who underwent Z-POEM for treatment of Zenker's diverticulum between 2018 and 2020 at a tertiary academic medical center compared to prior patients who had FES (between 2015 and 2018). Procedural characteristics and clinical outcomes (technical and clinical success, and adverse events) were compared between patients who underwent each treatment. RESULTS A total of 28 patients underwent ZD therapy during the study period. 13 patients (mean age 70 years; 77% male) underwent Z-POEM and 15 patients (mean age 72 years; 73% male) underwent traditional FES. The mean Zenker's diverticulum size was 2.4 ± 0.6 cm in the ZPOEM group vs 2.5 ± 0.8 cm in the FES group. The mean procedure time was similar between groups: 43.9 min (range 26-66) in the Z-POEM group and 60.2 min (range 25-92) in the traditional FES group (t = 1.74 p = 0.19). Overall technical success was seen in 100% of patients. There was one adverse event in the FES group (dehydration resulting in near-syncope) (1/28, 3.6%). Overall clinical success was seen in 92.8% (26/28) of patients and was not significantly different between groups (Z-POEM; 13/13, 100% vs FES; 13/15, 86.7%, t = - 1.36 p = 0.18). CONCLUSION This prospective study suggests that ZPOEM is an effective technique for the treatment of Zenker's diverticulum with no significant differences in clinical outcomes or adverse event rates when compared to traditional FES.
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Affiliation(s)
- Eric Swei
- Division of Gastroenterology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Sridevi K Pokala
- Division of Gastroenterology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Paul Menard-Katcher
- Division of Gastroenterology, University of Colorado School of Medicine, Aurora, CO, USA
| | - Mihir S Wagh
- Division of Gastroenterology, University of Colorado School of Medicine, Aurora, CO, USA.
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11
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Cadena Aguirre DP, de Moura DTH, Hirsch B, Peixoto de Oliveira GH, Kum AST, Mahmood S, Bernardo WM, Sharma NR, De Moura EG. Flexible Endoscopy Versus Rigid Endoscopy or Surgery for the Management of Zenker's Diverticulum: A Systematic Review and Meta-Analysis. Cureus 2023; 15:e43021. [PMID: 37680421 PMCID: PMC10480577 DOI: 10.7759/cureus.43021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/05/2023] [Indexed: 09/09/2023] Open
Abstract
Zenker's diverticulum treatment options range from endoscopic rigid or flexible procedures to surgery. There are limited studies available comparing these techniques. Frequently, the choice of treatment depends on the physician's preference or experience, as well as the institution's resources and capacity. Therefore, this study aims to define the best approach based on the highest efficacy and the lowest severe adverse events. In accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, a comprehensive search was performed. Only comparative studies were included, analyzing flexible endoscopy versus rigid endoscopy or surgery. The outcomes analyzed were clinical and technical success, severe adverse events, length of stay, and duration of the procedure. Analysis was performed using Review Manager 5.4.1 (RevMan 5.4, The Cochrane Collaboration, The Nordic Cochrane Centre, Copenhagen, Denmark). Eight retrospective cohort studies met the inclusion criteria. A total of 1281 patients were identified, 492 underwent flexible endoscopy, 453 underwent rigid endoscopy, and 336 underwent surgery. There was no difference in clinical success [risk difference (RD), 0.07 (95% CI -0.05 to 0.19%); P = 0.26], technical success [RD, 0.07 (95% CI -0.03 to 0.16); P = 0.18], severe adverse events [RD, -0.03 (95% CI -0.13 to 0.07; P = 0.052), perforation [RD, 0.07 (95% CI -0.04 to 0.19); P = 0.22] or procedure time [mean difference (MD), - 10.03 (95% CI -26.93 to 6.88); P = 0.24). There was lower length of stay with flexible endoscopy compared to the other approaches [MD, -1.98 (95% CI -3.56 to -0.40); P = 0.001]. Based on the current evidence, the three main techniques are effective for the treatment of Zenker's diverticulum. Although there was no significant difference in the safety of each technique in this meta-analysis, this result should be interpreted cautiously due to the limited data and the risk of vies between the techniques, considering that the results tend to favor flexible endoscopy, mainly explained by the newer and safer devices. Length of stay is lower with flexible endoscopy versus the other techniques, which can be beneficial considering the geriatric populations where Zenker's diverticulum mainly occurs.
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Affiliation(s)
- Diego P Cadena Aguirre
- Serviço de Endoscopia Gastrointestinal do Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, BRA
| | - Diogo Turiani Hourneaux de Moura
- Serviço de Endoscopia Gastrointestinal do Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, BRA
| | - Bruno Hirsch
- Serviço de Endoscopia Gastrointestinal do Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, BRA
| | - Guilherme Henrique Peixoto de Oliveira
- Serviço de Endoscopia Gastrointestinal do Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, BRA
| | - Angelo So Taa Kum
- Serviço de Endoscopia Gastrointestinal do Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, BRA
| | | | - Wanderley Marques Bernardo
- Serviço de Endoscopia Gastrointestinal do Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, BRA
| | - Neil R Sharma
- Division of Interventional Oncology and Surgical Endoscopy (IOSE), Parkview Health, Fort Wayne, USA
| | - Eduardo Guimarães De Moura
- Serviço de Endoscopia Gastrointestinal do Departamento de Gastroenterologia, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, BRA
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12
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Hollenbach M, Vu Trung K, Hoffmeister A. [Interventional endoscopy in gastroenterology]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2023:10.1007/s00108-023-01565-3. [PMID: 37405423 DOI: 10.1007/s00108-023-01565-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Accepted: 06/27/2023] [Indexed: 07/06/2023]
Abstract
Essential innovations in interventional endoscopy have significantly broadened the treatment armamentarium in gastroenterology. The treatment and complication management of intraepithelial neoplasms and early forms of cancer are increasingly being primarily addressed endoscopically. In cases of endoluminal lesions with no risk of lymph node or distant metastases, endoscopic mucosal resection and endoscopic submucosal dissection have become established as standards. For broad-based adenomas, coagulation of the resection margins should be performed in the case of a piecemeal resection. Submucosal lesions can be reached and resected by tunneling techniques. Peroral endoscopic myotomy in cases of achalasia is a new treatment option for hypertensive and hypercontractile motility disorders. In addition, endoscopic myotomy for gastroparesis has shown very promising results. In this article, new resection techniques and so-called third space endoscopy are presented and critically discussed.
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Affiliation(s)
- Marcus Hollenbach
- Bereich Gastroenterologie der Klinik für Onkologie, Gastroenterologie, Hepatologie und Pneumologie, Department für Innere Medizin, Neurologie und Dermatologie, Universitätsklinikum Leipzig AöR, Liebigstraße 20, 04103, Leipzig, Deutschland.
| | - Kien Vu Trung
- Bereich Gastroenterologie der Klinik für Onkologie, Gastroenterologie, Hepatologie und Pneumologie, Department für Innere Medizin, Neurologie und Dermatologie, Universitätsklinikum Leipzig AöR, Liebigstraße 20, 04103, Leipzig, Deutschland
| | - Albrecht Hoffmeister
- Bereich Gastroenterologie der Klinik für Onkologie, Gastroenterologie, Hepatologie und Pneumologie, Department für Innere Medizin, Neurologie und Dermatologie, Universitätsklinikum Leipzig AöR, Liebigstraße 20, 04103, Leipzig, Deutschland
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13
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Aden A, Bowen AJ, Richards B, Xie K, O'Byrne TJ, Storm A, Bayan SL, Alexander JA, Ekbom DC, Song LWK. Flexible endoscopic Zenker's diverticulotomy - A retrospective review of outcomes in 75 patients. Am J Otolaryngol 2023; 44:103864. [DOI: 10.1016/j.amjoto.2023.103864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 03/19/2023] [Indexed: 03/30/2023]
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14
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Steinway S, Zhang L, Amundson J, Nieto J, Desai P, Jacques J, Bejjani M, Pioche M, Kumta N, Hernandez-Mondragon O, Ujiki M, Khashab M. Long-term outcomes of Zenker's peroral endoscopic myotomy (Z-POEM) for treatment of Zenker's diverticulum. Endosc Int Open 2023; 11:E607-E612. [PMID: 37397859 PMCID: PMC10310448 DOI: 10.1055/a-2067-9105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 03/30/2023] [Indexed: 07/04/2023] Open
Abstract
Background and study aims Z-POEM is now an established therapy for symptomatic Zenker's diverticulum (ZD). Short-term follow-up of up to 1-year post Z-POEM suggests excellent efficacy and safety; however, long-term outcomes are not known. Thus, we sought to report on longer-term outcomes (≥ 2 years) following Z-POEM for treatment of ZD. Patients and methods This was an International multicenter retrospective study at eight institutions across North America, Europe, and Asia over a 5-year period (from December 3, 2015 to March 13, 2020) of patients who underwent Z-POEM for management of ZD with a minimum 2-year follow-up. The primary outcome was clinical success, defined as improvement in dysphagia score to ≤ 1 without need for further procedures during the first 6 months. Secondary outcomes included rate of recurrence in patients initially meeting clinical success, rate of reintervention, and adverse events (AEs). Results A total of 89 patients (male 57.3 %, mean age 71 ± 12 years) underwent Z-POEM for treatment of ZD (mean diverticulum size was 3.4 ± 1.3 cm). Technical success was achieved in 97.8 % of patients (n = 87) with a mean procedure time of 43.8 ± 19.2 minutes. The median post-procedure hospital stay was 1 day. There were eight AEs (9 %) (3 mild, 5 moderate). Overall, clinical success was achieved in 84 patients (94 %). Mean dysphagia, regurgitation, and respiratory scores all improved dramatically from 2.1 ± 0.8, 2.8 ± 1.3, and 1.8 ± 1.6 pre-procedure to 0.13 ± 0.5, 0.11 ± 0.5, and 0.05 ± 0.4, respectively, post-procedure at most recent follow-up (all P < 0.0001). Recurrence occurred in six patients (6.7 %) during a mean length of follow-up of 37 months (range 24 to 63 months). Conclusions Z-POEM is a highly safe and effective treatment for Zenker's diverticulum with durable treatment effect to at least 2 years.
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Affiliation(s)
- Steven Steinway
- Johns Hopkins Medicine, Gastroenterology and Hepatology, Baltimore, Maryland, United States
| | - Linda Zhang
- Johns Hopkins Medicine, Gastroenterology and Hepatology, Baltimore, Maryland, United States
| | - Julia Amundson
- University of Chicago Pritzker School of Medicine, Chicago, Illinois, United States
| | - Jose Nieto
- University of Central Florida, Department of Gastroenterology, Orlando, Florida, United States
| | - Pankaj Desai
- Surat Institute of Digestive Sciences, GI Endoscopy, Surat, India
| | - Jeremie Jacques
- CHU Dupytren Limoges, Service d'Hépato-gastro-entérologie, Limoges, France
| | - Michael Bejjani
- Johns Hopkins Medicine, Gastroenterology and Hepatology, Baltimore, Maryland, United States
| | - Mathieu Pioche
- Hôpital Edouard Herriot, Endoscopy Unit, Digestive Disease Department, Lyon, France
| | - Nikhil Kumta
- Icahn School of Medicine at Mount Sinai, Division of Gastroenterology, New York, New York, United States
| | | | - Michael Ujiki
- NorthShore University Health Systems, NorthShore Center for Simulation and Innovation, Evanston, Illinois, United States
| | - Mouen Khashab
- Johns Hopkins Medicine, Gastroenterology and Hepatology, Baltimore, Maryland, United States
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15
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Albéniz E, Marra-López Valenciano C, Estremera-Arévalo F, Sánchez-Yagüe A, Montori S, Rodríguez de Santiago E. POEM from A to Z: current perspectives. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2023. [PMID: 37073708 DOI: 10.17235/reed.2023.9602/2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
The "third space endoscopy" or also called "submucosal endoscopy" is a reality we can transfer to our patients since 2010. Various modifications of the submucosal tunneling technique allow access to the submucosa or deeper layers of the gastrointestinal tract. In addition to peroral endoscopic myotomy for the treatment of achalasia, also called esophageal POEM, other variants have emerged that make it possible to treat different esophageal motility disorders, esophageal diverticula, subepithelial tumors of various locations, gastroparesis, reconnection of complete esophageal strictures or even thanks to exceptional endoscopists, pediatric disorders such as Hirschsprung's disease. Although some technical aspects are yet to be standardized, these procedures are becoming widespread worldwide and will likely become the standard treatment of these pathologies soon.
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Affiliation(s)
- Eduardo Albéniz
- Endoscopy Unit. Gastroenterology, Hospital Universitario de Navarra (HUN). Navarrabiomed. UPNA, IdiSNA, España
| | | | | | | | - Sheyla Montori
- Gastrointestinal Endoscopy Research Unit, Hospital Universitario de Navarra (HUN). Navarrabiomed. UPNA, IdiSNA, Spain
| | - Enrique Rodríguez de Santiago
- Gastroenterology and Hepatology , Hospital Universitario Ramón y Cajal. Universidad de Alcalá. IRYCIS. CIBERehd. ISCIII, Spain
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16
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Zhang LY, Hernández Mondragón O, Pioche M, Steinway SN, Nieto J, Ujiki MB, VanDruff VN, Kim RE, Canakis A, Tantau M, Tantau A, Pop A, Jacques J, Lajin M, Desai P, Shrigiriwar A, Bejjani M, Kumta NA, Khashab MA. Zenker's peroral endoscopic myotomy for management of large Zenker's diverticulum. Endoscopy 2023; 55:501-507. [PMID: 36827992 DOI: 10.1055/a-2025-0715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
BACKGROUND Zenker's diverticulum peroral endoscopic myotomy (zPOEM) is a minimally invasive treatment strategy for Zenker's diverticulum, with excellent results for management of small-to-moderate Zenker's diverticulum. We evaluated its use in the management of large Zenker's diverticulum. METHODS This was a retrospective multicenter cohort study across 11 international centers including adult patients with large Zenker's diverticulum ≥ 40 mm treated by zPOEM between March 2017 and March 2022. The primary outcome was clinical success (dysphagia score ≤ 1 without need for further intervention). Secondary outcomes included technical success (complete myotomy as intended), adverse events (AEs), and rate of recurrence. RESULTS 83 patients (male 62.7 %, mean age 72.6 [SD 11.5] years) underwent zPOEM for treatment of large Zenker's diverticulum (median size 50 mm, interquartile range [IQR] 41-55 mm, range 40-80 mm). The zPOEM procedure was technically successful in 82 patients (98.8 %), with a mean procedure time of 48.7 (SD 23.2) minutes. Clinical success was achieved in 71 patients (85.5 %). Median (IQR) symptom scores improved significantly from baseline for dysphagia (2 2 3 vs. 0 [0-2]; P < 0.001), regurgitation (3 2 3 4 vs. 0 [0-0]; P < 0.001), and respiratory symptoms (2 [0-3] vs. 0 [0-0]; P < 0.001). Among patients achieving clinical success, only one recurrence (1.4 %) was recorded during a median follow-up of 12.2 months (IQR 3-28). Post-procedure AEs, all mild to moderate, occurred in four patients (4.8 %). CONCLUSION This study demonstrated safe and effective use of zPOEM in the management of large Zenker's diverticulum.
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Affiliation(s)
- Linda Y Zhang
- Johns Hopkins Medicine, Baltimore, Maryland, United States
| | | | | | | | - Jose Nieto
- Borland Groover, Jacksonville, Florida, United States
| | - Michael B Ujiki
- NorthShore University Health System, Evanston, Illinois, United States
| | | | - Raymond E Kim
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - Andrew Canakis
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland, United States
| | - Marcel Tantau
- "Prof Dr Octavian Fodor" Regional Institute of Gastroenterology and Hepatology, Cluj-Napoca, Cluj, Romania
| | - Alina Tantau
- Gastroenterology and Hepatology Medical Center, Cluj-Napoca, Cluj, Romania
| | - Anamaria Pop
- Gastroenterology and Hepatology Medical Center, Cluj-Napoca, Cluj, Romania
| | - Jérémie Jacques
- Hôpital Dupuytren, Servìce de Gastroentérologie, Limoges, France
| | - Michael Lajin
- Sharp HealthCare, San Diego, California, United States
| | - Pankaj Desai
- Department of Gastroenterology, Endoscopy Unit, SIDS Hospitals, Surat, India
| | | | | | - Nikhil A Kumta
- Icahn School of Medicine at Mount Sinai, New York, New York, United States
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17
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Hayat M, Yang D, Draganov PV. Third-space endoscopy: the final frontier. Gastroenterol Rep (Oxf) 2023; 11:goac077. [PMID: 36632624 PMCID: PMC9831051 DOI: 10.1093/gastro/goac077] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 11/16/2022] [Accepted: 11/22/2022] [Indexed: 01/11/2023] Open
Abstract
Over the years, our growing experience with endoscopic submucosal dissection along with technological advances has solidified our comfort and knowledge on working in the submucosa, also referred to as the "third space." Per-oral endoscopic myotomy (POEM) was the first prototype third-space endoscopy (TSE) procedure, demonstrating the feasibility and clinical utility of endoscopic esophagogastric myotomy via submucosal tunneling. The launch of POEM accelerated the evolution of TSE from a vanguard concept to an expanding field with a wide range of clinical applications. In this review, we discuss the status and future directions of multiple TSE interventions.
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Affiliation(s)
- Maham Hayat
- Center for Interventional Endoscopy, AdventHealth, Orlando, FL, USA
| | - Dennis Yang
- Center for Interventional Endoscopy, AdventHealth, Orlando, FL, USA
| | - Peter V Draganov
- Corresponding author. Division of Gastroenterology, Hepatology and Nutrition, University of Florida, 1329 SW 16th Street, Room #5254, Gainesville, FL 32608, USA. Tel: +1-352-273-9474; Fax: +1-352-627-9002;
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18
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Nabi Z, Reddy DN. Submucosal endoscopy: the present and future. Clin Endosc 2023; 56:23-37. [PMID: 36617645 PMCID: PMC9902679 DOI: 10.5946/ce.2022.139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 07/22/2022] [Indexed: 01/10/2023] Open
Abstract
Submucosal endoscopy or third-space endoscopy utilizes the potential space between the mucosal and muscularis layers of the gastrointestinal tract to execute therapeutic interventions for various diseases. Over the last decade, endoscopic access to the submucosal space has revolutionized the field of therapeutic endoscopy. Submucosal endoscopy was originally used to perform endoscopic myotomy in patients with achalasia cardia, and its use has grown exponentially since. Currently, submucosal endoscopy is widely used to resect subepithelial tumors and to manage refractory gastroparesis and Zenker's diverticulum. While the utility of submucosal endoscopy has stood the test of time in esophageal motility disorders and subepithelial tumors, its durability remains to be established in conditions such as Zenker's diverticulum and refractory gastroparesis. Other emerging indications for submucosal endoscopy include esophageal epiphrenic diverticulum, Hirschsprung's disease, and esophageal strictures not amenable to conventional endoscopic treatment. The potential of submucosal endoscopy to provide easy and safe access to the mediastinum and peritoneal spaces may open doors to novel indications and rejuvenate the interest of endoscopists in natural orifice transluminal endoscopic surgery in the future. This review focuses on the current spectrum, recent updates, and future direction of submucosal endoscopy in the gastrointestinal tract.
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Affiliation(s)
- Zaheer Nabi
- Asian Institute of Gastroenterology, Hyderabad, India
| | - Duvvur Nageshwar Reddy
- Asian Institute of Gastroenterology, Hyderabad, India,Correspondence: Duvvur Nageshwar Reddy Asian Institute of Gastroenterology, 6-3-661 Somajiguda, Hyderabad 500 082, India E-mail:
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19
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GIE Editorial Board Top 10: advances in GI endoscopy in 2021. Gastrointest Endosc 2022; 96:1062-1070. [PMID: 35948180 DOI: 10.1016/j.gie.2022.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 08/01/2022] [Indexed: 12/11/2022]
Abstract
The 9-member Editorial Board of the American Society for Gastrointestinal Endoscopy performed a systematic literature search of original articles published during 2021 in Gastrointestinal Endoscopy and 10 other high-impact medical and gastroenterology journals on endoscopy-related topics. Votes from each editorial board member were tallied to identify a consensus list of the 10 most significant topic areas in GI endoscopy over the calendar year of study, with a focus on 3 criteria: significance, novelty, and global impact on clinical practice. The 10 areas identified collectively represent advances in the following endoscopic topics: colonoscopy optimization, bariatric endoscopy, endoscopic needle sampling and drainage, peroral endoscopic myotomy, endoscopic defect closure, meeting systemic challenges in endoscopic training and practice, endohepatology, FNA versus fine-needle biopsy sampling, endoscopic mucosal and submucosal procedures, and cold snare polypectomy. Each board member contributed a summary of important articles relevant to 1 to 2 of the consensus topic areas, leading to a collective summary that is presented in this document of the "top 10" endoscopic advances of 2021.
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20
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Mandavdhare HS, Samanta J, Jafra A, Singh H, Gupta P. Recurrence after Zenker’s peroral endoscopic myotomy despite complete septotomy: how far to go with myotomy on the esophageal side. VideoGIE 2022; 7:350-352. [PMID: 36238802 PMCID: PMC9551619 DOI: 10.1016/j.vgie.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Harshal S Mandavdhare
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Jayanta Samanta
- Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anudeep Jafra
- Department of Anaesthesiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Harjeet Singh
- Department of Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pankaj Gupta
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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21
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Olson D, Liu KC, Aadam A. Peroral Endoscopy Myotomy (POEM) for Esophageal Motility Disorders. Curr Gastroenterol Rep 2022; 24:105-114. [PMID: 35947337 DOI: 10.1007/s11894-022-00845-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2022] [Indexed: 10/15/2022]
Abstract
PURPOSE OF REVIEW This review aims to provide an overview of the current role of per oral endoscopic myotomy (POEM) in the management of primary esophageal motility disorders and treatment of Zenker's diverticulum. RECENT FINDINGS POEM has been shown to be an effective treatment for achalasia. Recent research has suggested that the length of myotomy may be tailored to the disease phenotype and that short myotomy may be equally effective compared to long myotomy. The role of intra-operative EndoFLIP has shown promise as a tool to assess of the adequacy of myotomy. Further research is needed to determine the role of POEM in other esophageal motility disorders and for treatment of Zenker's diverticulum. Per oral endoscopic myotomy has been shown to be an effective and durable treatment option for achalasia with additional potential roles for the treatment of other esophageal motility disorders and Zenker's diverticulum.
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Affiliation(s)
- Dylan Olson
- Department of Medicine, Feinberg School of Medicine, Northwestern University, 251 E Huron St, 60611, Chicago, IL, USA
| | - Kevin C Liu
- Division of Gastroenterology and Hepatology, Banner University Medical Center, University of Arizona, Tucson, AZ, USA
| | - Aziz Aadam
- Division of Gastroenterology and Hepatology, Feinberg School of Medicine, Northwestern University, 676 N. Saint Clair Street, Suite 1400, 60611, Chicago, IL, USA.
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22
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Gkolfakis P, Costamagna G, Devière J. Zenker Diverticulum Treatment: The New Gold Standard Still to be Defined. J Clin Gastroenterol 2022; 56:552. [PMID: 35470285 DOI: 10.1097/mcg.0000000000001703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Paraskevas Gkolfakis
- Department of Gastroenterology Hepatopancreatology and Digestive Oncology, Erasme University Hospital Brussels, Belgium
| | - Guido Costamagna
- Surgical Digestive Endoscopy, Policlinico Gemelli, Università Cattolica, Rome, Italy
| | - Jacques Devière
- Department of Gastroenterology Hepatopancreatology and Digestive Oncology, Erasme University Hospital Brussels, Belgium
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Castaneda D, Franco Azar F, Hussain I, Lara LF, Pimentel RR, Alemar G, Hrelec C, Ponsky J, Erim T. A cooperative approach for treatment of Zenker's diverticulum. Surg Endosc 2022; 36:4129-4135. [PMID: 34524532 DOI: 10.1007/s00464-021-08736-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 09/06/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND Symptomatic Zenker's diverticulum management has evolved from an open intervention to an endoscopic management. At our center, both an otolaryngologist and a gastroenterologist are present in the operating room when treating these lesions. An intra-procedural consensus is reached to undergo either rigid endoscopy or flexible endoscopic diverticulotomy with ENT guidance. We evaluated the real-world efficacy with a cooperative gastroenterology-otolaryngology approach. METHODS Single-center retrospective study of patients who underwent a cooperative endoscopic diverticulotomy by a gastroenterologist and otolaryngologist at Cleveland Clinic Florida between 2012 and 2019. Demographic and clinical data, intra-procedural findings/complications, post-procedural symptoms, recurrence rate, and reintervention variables were extracted. Patients included in the study were > 17 years old, with symptomatic confirmed typical single Zenker's diverticulum. RESULTS 63 subjects were identified. Patients were predominantly males (63.5%) and white (84.1%), with mean age 73.5 years (53-95). Most subjects presented dysphagia (98.4%), mostly to solids (79.4%). Other demographic and clinical data are described in Table 1. The diverticula had a mean size of 36.3 mm. In 30.1% of the cases food debris was found during the procedure. The mean procedure length was 38.4 minutes. All cases were performed as outpatient. Technical success was achieved in all cases. Patients were followed for a mean of 3.24 months post-procedure. Clinical success was achieved in 92% subjects. One intra-procedural perforation was treated with endoclip. Table 1 Pre-procedural demographic and clinical variables in patients undergoing Zenker's diverticulum cooperative approach Variable Value (n = 63) Sex, n (%) Male Female 40 (63.5) 23 (36.5) Ethnicity/Race, n (%) Non-Hispanic White Hispanic Black 53 (84.1) 7 (11.1) 3 (4.8) Smoking status, n (%) Never Former Active 29 (46.0) 26 (41.3) 8 (10.7) Previous intervention for Zenker's diverticulum, n (%) 12 (19.1) Dysphagia, n (%) Only to solids Only to liquids Both solids and liquids 50 (79.4) 0 (0) 12 (19.0) Regurgitation of food, n (%) Chronic cough, n (%) 13 (20.6) Halitosis, n (%) 9 (14.3) CONCLUSION: A cooperative endoscopic approach by gastroenterology and otolaryngology for symptomatic Zenker's diverticulum management offered excellent technical and clinical success. This approach proved to be safe and effective.
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Affiliation(s)
- Daniel Castaneda
- Digestive Disease Institute, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, 2nd Floor, Weston, FL, 33331, USA.
| | - Francisco Franco Azar
- Digestive Disease Institute, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, 2nd Floor, Weston, FL, 33331, USA
| | - Ishtiaq Hussain
- Digestive Disease Institute, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, 2nd Floor, Weston, FL, 33331, USA
- Medicine Department, Weiss Memorial Hospital, Chicago, IL, USA
| | - Luis F Lara
- Department of Gastroenterology, Wexner Medical Center, The Ohio State University, Columbus, OH, USA
| | - Ronnie R Pimentel
- Digestive Disease Institute, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, 2nd Floor, Weston, FL, 33331, USA
| | - Gilberto Alemar
- Department of Otolaryngology, Cleveland Clinic Florida, Weston, FL, 33331, USA
| | - Candace Hrelec
- Department of Otolaryngology, Cleveland Clinic Florida, Weston, FL, 33331, USA
| | - Jeffrey Ponsky
- Department of Surgery, Cleveland Clinic, Weston, FL, 33331, USA
| | - Tolga Erim
- Digestive Disease Institute, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd, 2nd Floor, Weston, FL, 33331, USA
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Familiari P. Endoscopic treatment of Zenker's diverticulum: a never ending (r)evolution. Endoscopy 2022; 54:352-353. [PMID: 34560792 DOI: 10.1055/a-1616-1092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Affiliation(s)
- Pietro Familiari
- Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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25
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Zhang H, Huang S, Xia H, Shi L, Zeng X, Jiang J, Ren W, Peng Y, Lü M, Tang X. The role of peroral endoscopic myotomy for Zenker's diverticulum: a systematic review and meta-analysis. Surg Endosc 2022; 36:2749-2759. [PMID: 35020054 DOI: 10.1007/s00464-022-09021-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 01/03/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Zenker's peroral endoscopic myotomy (Z-POEM) has revolutionized the therapeutic strategy for Zenker's diverticulum (ZD) with promising results. We conducted this meta-analysis to estimate the safety and efficacy of Z-POEM for ZD and compare the feasibility and effectiveness of Z-POEM with that of flexible endoscopic septotomy (FES). METHODS A comprehensive literature search was conducted in PubMed, EMBASE, Web of Science, and Cochrane Library databases to query for studies that assessed the safety and efficacy of Z-POEM for ZD. All articles published from inception to July 31, 2021 were included. The primary outcomes were the overall technical success rate, clinical success rate, incidence of adverse events, and clinical recurrence rate. RESULTS Eleven studies involving 357 patients undergone Z-POEM were included. Overall, the quality of included studies was above average, with five studies rated as high quality and six ranked as moderate quality. The overall pooled technical success rate for Z-POEM was 96.3% (95% confidence interval [CI] 93.6-97.9%; I2 = 0%). The total pooled clinical success rate for Z-POEM was 93.0% (95% CI 89.4-95.4%; I2 = 0%). The pooled incidence of adverse events for Z-POEM was 12.4% (95% CI 9.1-16.7%; I2 = 0%). The pooled clinical recurrence rate for Z-POEM was 11.2% (95% CI 7.6-16.2%; I2 = 0%). The clinical success for Z-POEM was significantly better than that of FES (relative risk [RR]: 1.11; CI 95% 1.03-1.18; p = 0.004, I2 = 0%), while there were no significant differences in technical success, adverse events, and clinical recurrence between Z-POEM and FES. CONCLUSION Z-POEM could be an effective and safe therapeutic modality for ZD, and even has a slightly higher clinical success rate than FES. However, comparative studies with long-term follow-up will be needed to further confirm our finding.
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Affiliation(s)
- Han Zhang
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099, Sichuan Province, China.,Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, China
| | - Shu Huang
- Department of Gastroenterology, The People's Hospital of Lianshui, Huaian, China
| | - Huifang Xia
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099, Sichuan Province, China.,Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, China
| | - Lei Shi
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099, Sichuan Province, China.,Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, China
| | - Xinyi Zeng
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099, Sichuan Province, China.,Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, China
| | - Jiao Jiang
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099, Sichuan Province, China.,Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, China
| | - Wensen Ren
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099, Sichuan Province, China.,Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, China
| | - Yan Peng
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099, Sichuan Province, China.,Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, China
| | - Muhan Lü
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099, Sichuan Province, China. .,Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, China.
| | - Xiaowei Tang
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Street Taiping No.25, Region Jiangyang, Luzhou, 646099, Sichuan Province, China. .,Nuclear Medicine and Molecular Imaging Key Laboratory of Sichuan Province, Luzhou, China.
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26
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Abstract
AbstractThird space or submucosal space is a potential space which on expansion allows the endoscopist to execute a multitude of therapeutic procedures for various gastrointestinal diseases like achalasia, subepithelial tumors, Zenker’s diverticulum, and refractory gastroparesis. Third space was first utilized for performing endoscopic myotomy in cases with achalasia cardia about a decade ago. Since then, the field of submucosal endoscopy has witnessed an exponential growth. The present review focuses on recent advances in the field of third-space endoscopy. With regard to per-oral endoscopic myotomy (POEM) in achalasia cardia, several recent studies have evaluated the long-term outcomes of POEM, compared endoscopic myotomy with pneumatic dilatation (PD) and surgical myotomy, and evaluated the outcomes of short- versus long-esophageal myotomy. In addition, the utility of multiple dose antibiotic prophylaxis to prevent infections after POEM has been questioned. Overall, the results from these studies indicate that POEM is a durable treatment modality, equally effective to Heller’s myotomy and superior to PD. With regard to gastric-POEM (G-POEM), recent studies suggest only modest efficacy in cases with refractory gastroparesis. Therefore, quality studies are required to identify predictors of response to optimize the outcomes of G-POEM in these cases. Another third-space endoscopy procedure that has gained popularity is endoscopic division of septum in cases with esophageal diverticula including Zenker’s POEM and epiphrenic diverticula POEM (Z-POEM and D-POEM, respectively). The technique of diverticulotomy using the principles of submucosal endoscopy appears safe and effective in short term. Data on term outcomes are awaited and comparative trials with flexible endoscopic myotomy required. Per-rectal endoscopic myotomy (PREM) is the most recent addition to third space endoscopy procedures for the management of short-segment Hirschsprung’s disease. Limited data suggest that PREM may be a promising alternative surgery in these cases. However, quality studies with long-term follow-up are required to validate the outcomes of PREM.
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Affiliation(s)
- Zaheer Nabi
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - D Nageshwar Reddy
- Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
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