Hello, everyone. Welcome to our fourth session in virtual esophagology. It is my pleasure to co-moderate the session with Dr. Irving Waxman, who most people know as the director of the Center for Endoscopic Research and Therapeutics at University of Chicago, but I know him as the person who got me interested in the esophagus and endoscopy. So thank you, Irving, for joining us. Thank you, Vani, and thanks, Dr. Sharma, for your kind invitation to participate this afternoon in this excellent course. I think we're going to start this session, and it gives me great pleasure to introduce our first speaker, Dr. Mohan Kashyap, who's Associate Professor of Medicine and Director of Therapeutic Endoscopy, Lead Therapeutic Endoscopy Group at Johns Hopkins. Mohan is truly a trade blazer in the field, so I'm really excited hearing his presentation. Hello, everyone. My name is Mohan Kashyap from Johns Hopkins Hospital, and I'll be speaking today on Zenker's diverticulum. These are my disclosures. Current options for Zenker's diverticulum include surgical options. In the past, an open myotomy and open diverticulotomy used to be the standard treatment options. However, these surgeries are associated with significant morbidity and some mortality. For the most part, these surgeries have been abandoned. Other options include rigid endoscopy with stapled diverticulotomy, rigid endoscopy with laser diverticulotomy, in addition to other techniques that are performed via rigid endoscopy by our ENT colleagues. And finally, as you know, the different flexible endoscopic options that include standard septotomy and more recently, Zenker's peroral endoscopic myotomy. Fundamental step in the management of Zenker's diverticulum lies in dividing the cricopharyngeus muscle fibers. As we can see in this figure, the treatment relies on dividing the Zenker septum. This is clearly shown in figure C and D. Dysphagia and regurgitation are related to that partition between the diverticulum and the esophageal lumen. Cutting the septum or endoscopic septotomy gets rid of this septum and then the diverticulum can readily empties into the esophageal lumen, eliminating patient's symptoms. This septotomy can be performed via a standard endoscopic septotomy approach or as I already mentioned, Zenker's PEROM. This figure depicts a standard septotomy. This septum separates, as I already showed you, the esophageal lumen from the diverticulum. Different cutting knives can be used to divide the septum. Therefore, now the esophageal diverticulum can readily empties into the esophageal lumen. The main problem with this approach is that it is hard to delineate the bottom of the septum. Therefore, part of the septum is left, typically at least five millimeters, to ensure that perforation does not happen. Leaving septum behind is believed to result in an increased rate of recurrence during long-term follow-up with the standard septotomy approach. This is a video that will show you a standard septotomy approach. This is a gastroscope with a cap, and you can notice that there is a nasogastric tube in the esophageal lumen. This is to delineate the septum itself and also to give us some spacing away from the esophageal wall to ensure that there's no coronary-related injury to the wall. In this example, the septotomy is being performed using a scissor-type knife. Typically, we use an endocut Q current for the septotomy. Once we reach or we're close to the bottom of the septum or the bottom of the diverticulum, a couple of clips are placed to diminish the risk of perforation and delineating. This is one of the best studies published on outcomes of this approach, the outcomes of standard septotomy. This is from Brussels. 150 patients were followed up, and during long-term follow-up, you can see that there was a recurrence rate of 23%. So, significant recurrence rate even in expert hands. And as I mentioned before, this is likely related to leaving some septum behind. This is the reason why Zinker's peroral endoscopic myotomy was introduced. The first report was published by a Chinese group in gastroenterology, and then we started performing it in the United States and around the world. I will show you several videos depicting how we progressed or we changed the technique over time to optimize it. This is a technique where this procedure, as you can see here, was performed in 2017. A bleb and incision were performed a couple of centimeters proximal to the septum itself. So, the incision is in the hypopharynx. This is a very narrow space and a space that's not very familiar to us. Once we tunnel towards the septum, then tunneling on both sides of the septum are performed. Here, the septotomy is performed using the insulated tip knife and also the triangular tip knife. We'll show you later how the use of knife has also changed to render the technique a little more efficient. Here, basically, we like to tunnel to the bottom of the septum. There's no limit to the length of septotomy that we can perform here. And that's the advantage of Zenker's poem as opposed to a standard septotomy procedure. Here, we're using, we're closing the incision using standard clips. This used to be a major hurdle as closure in this narrow space was difficult. Another example how the technique evolved. Here, we're getting closer to the septum, but we're still tunneling proximally. The septum. This is, of course, posterior, so we make an incision. To enter into the tunnel, you have to turn your scope by 180 degrees. That facilitates pushing the scope into the tunnel. Here, we identify the septum and we tunnel similar to standard esophageal poem on both sides of the septum here. And here, we're using the scissor type knife. I think this is the best knife to use for the septotomy itself. It makes the procedure pretty fast. It's very effective and you can selectively cut the muscle and ensure you're cutting away from the esophageal wall. Again, here, there's no limit to the septotomy. We extend the septotomy by a couple of centimeters into the upper esophagus. And then, at the end, close the incision with clips. Here, we're using standard clips. So, it's very proximal in the hypopharynx and this used to be a little different. The technique evolved to now where the incision, a bleb and incision are performed exactly over the septum rather than proximal to the septum. So, this is, in my opinion, the optimal technique. So, this is an injection bleb formation, then incision over the septum itself. So, then this eliminates the need to tunnel towards the septum. If there's difficult anatomy, hitting the septum from a proximal tunnel may be difficult. You can deviate away from the septum. More importantly, now, if you tunnel over the septum, closure becomes easier since there is more space at the level of the septum rather than the narrow space more approximately in the hypopharynx. Here, once we tunnel over the septum, we continue to tunnel to the right and to the left as I've already shown you. Then, to expose the septum, tunneling is performed on the surface of the septum. Stay away from the esophageal mucosal, as always with submucosal endoscopy to protect the mucosal layer. Then, a standard septotomy is performed using endocut Q current. And here you see the larger space over the septum with the over the septum technique, and this will render closure much easier. Also, one thing we changed is now we use clips with shorter stems to eliminate or diminish the risk of foreign body sensation. And also using these clips with shorter stems also ensures that you have adequate working space for complete closure. Here, by placing the first clip, the edges come together and then closure becomes relatively variable. This is a hybrid technique that we described a year and a half ago in patients with prior treatment. Some patients with prior therapy will have extensive submucosal fibrosis, and thus a pure submucosal or a pure POM approach will not be feasible because, as you can see here, there is some fibrosis. So what we do is we start with a standard septotomy technique, like I've showed you the initial video, and once we have clear submucosal space, then we switch to a POM technique. And that's what matters. So what matters is how we cut the bottom of the septum to ensure complete septotomy. So if we perform a standard septotomy on top of the septum, that's not going to affect what happens at the bottom of the septum. So here, just a standard septotomy until you hit a clear submucosal space, as you can see here. Once this happens, then we can continue with a POM or submucosal endoscopy technique to ensure that a complete septotomy is performed. So this is how we perform the hybrid technique. In some patients with prior treatment, you will not encounter any submucosal fibrosis. So you can do a Z-POM throughout the procedure without any problems. But in some patients with extensive submucosal endoscopy, a hybrid technique can be performed. This is a video depicting a cricopharyngeal bar myotomy. Some patients will have this cricopharyngeal bar with tight upper esophageal sphincter and significant dysphagia. These patients can also be treated via a technique similar to a Z-POEM. Here we tunnel proximal to the bar. The bar is delineated by endoscopy. It's a tight area where, as you saw, we had difficulty passing through. We tunnel, we hit the bar, we continue to tunnel distal to the bar, and then using here the insulated tip knife, perform a complete myotomy, and then repeat endoscopy with easy traversing or passing the upper esophageal sphincter. Here tunneling has to be performed proximal to the bar, so expect some relative difficulty in closing the incision. This is another example of a relatively rare case of a cricopharyngeal bar associated with a diverticulum. So here you saw a tight upper esophageal sphincter. You pass it, and a little distally you see a diverticulum. So here we want to perform both a CP myotomy and a septotomy. Here the diverticulum was a little distal to the upper esophageal sphincter. So we tunneled through the UES towards the septum, and then tunneled to the right and the left of the septum, and then you perform a septotomy, and then you perform a CP myotomy, and then make sure both myotomies meet. This is a similar approach to the way we treat patients with epiphrenic diverticula associated with esophageal outflow obstruction, like epiphrenic diverticula with achalasia. This is an international study we published in 2019 in Gastrointestinal Endoscopy, the first multicenter study on Z-POEM for Zenker's diverticulum in 75 patients. Although this was our initial experience, clinical success was excellent, 92%, technical success, 97%. Procedure time used to be long, 52 minutes, and now it is much, much shorter than that. Mind you that some perforations, some mucosotomies, some bleeding can happen. Here in this study, these were treated successfully with endoscopy. There was one severe perforation that necessitated intensive care unit monitoring, so it's really important. Closure is very important, and I think with the new technique of over-the-septum tunneling, I think this might decrease the risk of perforation and leakage due to adequate or secure, or easier secure closure. I also wanted to mention this study that's in press and endoscopy of impact of prior treatment on Z-POEM. We included 32 patients that had different types of prior treatment, including open surgery, rigid endoscopy, flexible endoscopic septotomy, and Z-POEM. And you can see here that despite prior treatment, the success was 96%. The dysphagia score went from 2 to 0, and a pure Z-POEM technique was performed in 28 out of 30 successful procedures. A hybrid technique like the one I showed you was used in 2, and 2 procedures failed, and a Z-POEM could not be performed, so a standard septotomy was successfully performed. In conclusion, Zanker's therapy using flexible endoscopic approach is effective and safe. Symptom recurrence is not uncommon. Z-POEM is theoretically superior in terms of symptom recurrence, but comparative trials are needed. Z-POEM technique has evolved, and over-the-septum approach simplifies the procedure. Thank you for your attention.

Zenker's diverticulum

treatment options

surgical options

endoscopic options

Z-POEM