Good evening, and welcome, everyone, to ASGE's Thursday Night Lights on Diagnosing and Management of Esophageal Diverticula, will be presented by Dr. Ryan Law tonight. My name is Ed Dillard. I'm the Chief Publications and Learning Officer here at ASGE. Very excited to be having you all join us this evening for tonight's presentation. You should all be with us in the platform that ASGE leverages every Thursday evening on our webinars. You're in the auditorium right now listening to our presentation, but there's other features in this platform that you're welcome to peruse at your leisure after the webinar. There is our lobby level, which is up in the upper left-hand corner here. You can find more meeting information for tonight's webinar there. Satellite Symposia, our previous recorded presentations that you can go in and access at any time. We also have a resource room, which is kind of like an ASGE library, where you can find different pieces of information that ASGE has to offer. If you look at the GI Leap, you can access certain features that are on GI Leap. There's a game room that's on EOS and ERCP as an example. We also have some master videos from VideoGIE in the large screen there in the background. We also have some information and little quizzes on the brief history of endoscopy, if you're interested in that. And then our latest guideline access, those are accessible there as well. So there's a lot of features that are available in and around this platform. Feel free to leverage any of those as you wish. As with all our Thursday evening webinars, they are being recorded and they will be available within the next couple of days on GI Leap, our learning management system platform. You can get a copy at the URL that is listed on your screen currently. Tonight's objectives for this presentation is fourfold. Our hope is that you'll be able to understand the most important signs and symptoms of esophageal cancer, why it appears and how to detect it. Number two is discuss common symptoms and how patient presentation could include other pathologies. Three is describing the various series of imaging and lab studies commonly conducted to reach to a definitive conclusion. And number four is identify a surgical and endoscopic techniques in the treatment considerations. So it's my pleasure to introduce our presenters here, our moderators. We've got two advanced fellows with us tonight. I'll start from the right, working my way left here. So first advanced fellow is Kelly Hawthorne. She's at the University of North Carolina and she is very excited. She's just finishing up her advanced endoscopy fellowship within the matter of the next week or two. As is Sean Bale, who is an advanced endoscopy fellow who's just completing his year on the next few days at the University of Michigan. And then finally, our key presenter tonight is Dr. Ryan Law. He's a longstanding ASGE member. I've worked with Dr. Law on a number of companies, a fantastic volunteer and leader. He's been in the gastroenterology practice and advanced training of complex endoscopic procedures for a long time, focusing on ERCP, diagnostic and therapeutic EOS, submucosal endoscopy for the treatment of gastroparesis and dinkers diverticulum, and endoscopic resection of large and complex colorectal polyps. He's an active clinical researcher, as well as a phenomenal educator of residents and fellows. He's been on the editorial board of many gastroenterology journals, including our video GIE journal in the past, and has spoken on a variety of GI endoscopic disorders across the country and internationally. It is our great pleasure to introduce Dr. Law. Thank you. Hello, everyone. First and foremost, I would like to thank ASGE for the opportunity to speak. Secondly, I'd like to thank Dr. Hathorn and Dr. Bala for joining me for the presentation tonight. So we'll kind of keep this more of a pragmatic approach as opposed to a lot of fluff with pathophysiology history, that sort of thing. I think that the stuff that's most important is kind of diagnosis and management. We'll talk mostly about Zenker's diverticulum, as this tends to be the most common type of esophageal diverticulum that we do see. We'll then spend a little bit of time on Killian-Jameson diverticulum, particularly how to discern that from a Zenker's diverticulum, and then a few minutes each on mid-esophageal diverticulum and epiphrenic diverticulum. So we can really discuss diagnosis pretty much in one slide. You know, the symptoms for all of these diverticula are generally the same, at least in some form or fashion, with the most common symptom being dysphagia. Other symptoms such as halitosis, cough, potentially aspiration, pneumonia, food regurgitation, and then in the most extreme circumstances, weight loss and malnutrition. And certain patients with cervical diverticula, such as Zenker's or Killian-Jameson, can actually have a palpable neck mass or cervical borborigmas. From a definitive diagnosis perspective, typically it's a combination of radiology and endoscopy, sometimes one or the other, but generally speaking, patients end up getting both. From a radiology perspective, the most commonly used test is the esophagram. This is the best test to identify the esophageal diverticulum, though cross-sectional imaging can be used as well. It's a much more expensive modality. You get a bit more information with the esophagram in terms of some idea of esophageal motility and so forth. From an endoscopic perspective, you know, endoscopy can be considered a confirmatory test, however, one must consider that even passage of an endoscope in the setting of somebody with a suspected diverticulum, there is a risk of perforation. The risk is likely a bit higher with Killian-Jameson or Zenker's diverticulum than mitosophageal or epiphrenic just because of the very proximal location of Killian-Jameson or Zenker's. The other important thing to note that I always discuss with fellows is passage of non-forward viewing endoscopes such as an oblique EUS scope or a duodenoscope in elderly patients or patients who you suspect could have a diverticulum. It's best to go slow. If you end up getting into a diverticular pocket, it's easy to reposition the scope, but just something to think about every time you pass a non-forward viewing scope in an elderly patient. So with that, we'll kind of jump right into it, and like I said, we'll spend the bulk of the time on Zenker's diverticulum, there's probably the most to say about that fourfold. So, you know, when we think about the management of Zenker's diverticulum, historically, this was managed with an open surgical approach, either with diverticula pexi, where the diverticulum was essentially affixed to the proximal esophageal wall, or diverticulectomy through an open neck incision, where the actual diverticular sac is removed. Diverticulectomy is, you know, and diverticula pexi are significantly more morbid than more traditional approaches, which include a rigid endoscopic approach and a flexible endoscopic approach. The rigid endoscopic approach is most commonly performed, at least in the United States, by ENT surgeons, potentially some thoracic surgeons, and they place a rigid diverticula scope, either a WERDA or a Dolman diverticula scope, which I will show you an image of here in the next couple of slides, across the diverticular septum with septum division, then performed using a variety of tools. The flexible endoscopic diverticulotomy approach was first described in 1995, almost in parallel by Ishioka and Mulder. And since that time, there's been some changes in approach with newer techniques, and also newer devices, you see at the lower part of the screen, a variety of tools, which have been used for endoscopic septum division, including a hook knife, an SB knife, and then more to the right, you see a clutch cutter, and then hot biopsy forceps. I don't know of any data that suggests that one particular tool is better than the other. I would just suggest, for those who are going to incorporate this into their practice, that you pick a device and become comfortable with that, and go with that. I personally use, in my practice now, an SB knife, which is the second from the left, because I think it provides, you know, exactly what you need for that approach. So we'll speak briefly again about the open surgical approach. So this is a transcervical diverticulotomy. If you look at panel A, you'll see the clamps on the distal aspect of the Zenker's diverticulum. In panel B, you'll see, again, a different view of the diverticulum, but also the cricopharyngeus. So you'll see how the Zenker's has kind of ruptured through the cricopharyngeus, keeping in mind that the Zenker's is a false diverticulum in comparison to other types, which end up being a true diverticulum. This is simply a kind of pulsion through the proximal esophageal wall. So from the rigid endoscopic approach, here's a Dolman diverticuloscope on the left and a Wierda diverticuloscope on the right. I don't know that one is any better than the other. Both work upon kind of a bivalve approach, whereby the diverticular septum can be isolated between the two aspects of the scope and thereby stabilize it for septum division. I would say most commonly, when this is performed in the U.S., from what I know, most ENT surgeons who do this prefer the stapled approach. So you can see in panel B, it's a bit difficult to see with some of the blood, but essentially what they're trying to describe is that the diverticular septum is isolated using the rigid scope, and then the linear stapler is passed through the diverticuloscope and the staples are fired following the staples being fired. The septum is divided, as you can see here in panel C. You have staples on both sides, and then the septum is cut down the middle. One important point to keep in mind with patients who undergo a rigid endoscopic approach is that the nose of the stapler does not have staples which fire. So you can see if you look to the right of the screen, these are two different types of linear staplers. There is about a five to seven millimeter nose on the tip of the stapler, and that may lead to creation of a small residual diverticular pouch following the procedure. Now whether that's clinically significant, you know, remains to be seen. In some patients it may be, and you may find some patients where it's not. Another important point to keep in mind is that following septum division, no matter what approach you use, at least endoscopically, a post-procedure esophagram, which shows a small residual pouch, may or may not correlate to the patient's symptoms or lack thereof. So you may see patients who have a small residual pouch who tell you that they're 90% improved, and vice versa, you may have patients who have a bit more symptoms related to that pouch. So it's kind of on a case-by-case basis, but just something to note, if you do see a patient who had a prior rigid endoscopic procedure, it was likely with a linear stapler, and their symptoms may be related to that residual pouch, which can be addressed in a subsequent procedure with very little difficulty. So as an alternative to the linear stapler is CO2 laser. This is still performed at some centers. Some centers actually prefer this. Again, here in panel A, you see the diverticular septum being isolated by the rigid diverticuloscope, and then B shows the initial incision using the CO2 laser, with panel C showing a complete cricopharyngeal myotomy. Just something to be aware of, again, I think at most institutions, the linear stapled approach has been preferred. There's been a variety of other techniques, for example, there's case reports of people using a rigid diverticuloscope with a harmonic scalpel, a lot of ways to skin a cat when it comes to treating Zenkers. So next we'll kind of switch gears and talk the remainder, at least the time on Zenkers, about flexible endoscopic approaches. What I call the conventional approach, or the CP myotomy, is essentially septum division freehand using a variety of the tools that we've previously described. You can see here on this schematic, panel B basically is post myotomy, where you kind of get this V-shaped cut. Again, we're basically trying to create a common channel between the diverticular pouch and the true esophageal lumen, and that's best demonstrated on the sagittal views here between C and D. So we aren't resecting the pouch, we're just trying to create a common channel such that any food that passes into this pouch can freely pass to the distal esophagus. And data, meta-analysis data from SAUD-ESHAC, 20 studies including over 800 patients, the success rate of this approach was more than 90%. There was an 11% recurrence rate and an adverse event rate north of 10% as well, with the two main adverse events being perforation and bleeding. A perforator's diverticulum can be pretty vascular structure, so that's something to keep in mind. Something to keep in mind for your preparation before you start the case is to have available tools close by for hemostasis. In terms of perforation, you know, being able to discern the buccopharyngeal fascia when you get to, you know, towards the end of the diverticular wall is challenging. So, you know, if you do go too deep, you know, you end up in the mediastinum. So patients, you know, may have mediastinal error, patients may get a pneumothorax or have crepitus in the neck. I typically routinely check throughout the procedure, palpating the patient's neck, chest, face, shoulders, to see if I'm able to palpate any crepitus or subcutaneous emphysema. It shouldn't necessarily deter you from continuing on with the case, but it's definitely something to note and make sure that the anesthesiologist is aware as well. Obviously, all of these procedures will be performed using CO2 and not air, which kind of limits bad things happening if there is any sort of air tracking throughout the subcutaneous tissues. So there is an additional meta-analysis that shows essentially the same data, however, it does note that adverse events are increased in patients with the Zenkers greater than four centimeters, at least when it comes to the conventional approach. What I can tell you is some of that may be related to the fact that as you divide the cricopharyngeal septum in a patient with a really large Zenkers, you do create quite a sizable defect that you really can't oppose. You may see case reports or even people at your own institution, if they're performing these procedures, that after the myotomy, they'll place clips at the base of the septotomy. For really large diverticulum, it's pretty hard to oppose the tissue. You get quite a sizable defect. So it's not surprising, per se, that patients with a really large Zenkers, you know, have a bit more issues in terms of adverse events. So before we talk about some of, or show some of the videos about the different approaches, some of you may have seen or be aware of the flexible, soft flexible diverticuloscope that is available, not in the US but in many countries. Essentially, this is an overtube, a bivalve overtube that you can scope through, with the whole idea being that this provides stabilization of the septum similar to the rigid diverticuloscopes available. Again, not available in the US, but there's certainly a plethora of videos out there demonstrating the flexible diverticuloscope. So here we will show a video. So this is a conventional CP myotomy where we cut mucosa as well as submucosa and muscle. Again, my preference from a device perspective is the SB knife. There's three sizes of the SB knife. I think there's a junior, a short, and a standard, I believe. The smallest one, I believe it's the short, is the one that's least useful. It's quite small, but the other two versions certainly can be used. And here you see we just basically grasp the diverticular septum. And as we're applying cautery, we're retracting the SB knife and eventually we're able to divide the whole cricopharyngeal septum. In terms of settings, it's a bit of personal preference. I tend to use, if I were using an Irby generator, it would be an Endocut I111. And again, my personal choice for using that device is that you're able to grasp the tissue and kind of stabilize things as you cut, as opposed to a needle knife or the various needle knife iterations where it's a bit more freehand. Another important point that I would make that I didn't do in that particular case, but is a good practice, is prior to any septum division, it's certainly worthwhile to place either a nasogastric tube or even a small caliber feeding tube, like a 10 or 12 French feeding tube, down the true esophageal lumen. This is for two reasons. Reason number one is that it provides a landmark. So particularly in larger diverticulum, as you're cutting, it doesn't take much to get disoriented. So knowing where the true esophageal lumen is, is of paramount importance, particularly in larger diverticulum. The other reason why that's beneficial is in the unfortunate event where you have perforation or adverse event, you know, that's not something that you want to try and place in the context of having, you know, something going on. You want to have that there to feed the patient potentially if you need the proximal esophagus and or mediastinum to heal. It's much better to place that up front than try to place it when you actually need it. And it can be easily removed at the end. Again, clip placement at the end is personal preference. I most frequently do not place clips. I don't know there's any data to suggest that they're beneficial. Some people do. I think it's just literally personal preference. All right, so the newest kid on the block is the Zenker's poem approach. So this was initially described in 2016 by the group in Shanghai. And the whole goal was to reduce on a 6% perforation rate with traditional or conventional endoscopic septum division or cricopharyngeal myotomy. This was developed using the same principles of esophageal poem with the goal to allow improved visualization of the cricopharyngeal muscle during division. There is some idea that this allows complete division of the cricopharyngeus. I think it's still somewhat challenging to discern when you're at the base of the diverticulum, but I would say in my experience that the visualization is improved. So in terms of data on the Z-Poem approach, there's not a ton. Most of it's retrospective. Actually, all of it's retrospective. Probably the largest series is a series of 75 patients from 10 centers around the world with a mean diverticulum size of 3 centimeters, but a range up to 9 centimeters. Technical success, 97%. Clinical success, meaning resolution of symptoms, 92%, with notable improvement in dysphagia scores. At 12-month follow-up, only one patient reported persistent symptoms. Interestingly, the adverse event rate was minimally lower, but not likely significantly lower when compared to the cricopharyngeal myotomy, the conventional approach. Again, the same typical adverse events of bleeding and perforation with a procedure time of 52 minutes and a hospital stay of almost two days in these patients. So there's another approach that can be considered that we do Z-Poem following a prior conventional flexible endoscopic CP myotomy or a prior surgical therapy. Technical success, minimally lower. Very good clinical success. However, the likelihood of technical failure is certainly higher, given the inability to create a tunnel, and the absence of staples if this were following a rigid approach with a linear stapler. And then obviously the fibrosis in the area is something that you'll have to contend with in terms of dissection prior to myotomy. Again, you see a reduction in dysphagia score, and this was a follow-up approximately 160 days. Again, for adverse events, leaks and mucosotomies, not a huge surprise given the likelihood of difficulty with submucosal tunneling. So again, here's just a schematic, and this is actually for esophageal poem, but we show injection of submucosal fluid, mucosotomy, entry into the tunnel, creation of the submucosal tunnel, followed by myotomy, and then mucosal closure. While this relates to the esophagus and is for a completely different indication, the steps technically are the same, and the approach is the same. From the paper from the Shanghai group, this is a schematic which shows how the Zinker's poems performed. You see submucosal injection basically in line with the cricopharyngeal septum, but about two centimeters proximal to it. The submucosal bleb is then incised, and the scope is entered in the submucosal space, and then a tunnel is created in parallel on both sides, one down the true esophageal lumen and then one down the diverticular lumen. Keep in mind that the diverticulum is a false diverticulum, so you're not going to see the same anatomic landmarks when you tunnel in that direction. Oftentimes, it's a bit disconcerting because you're into an open space and there's really nothing there. There's no muscle, there's no relevant landmarks. It can be concerning for perforation, but that's just kind of how that diverticular space appears. So that's definitely something to keep in mind. It's very different than what you see on the esophageal side where it's conventional with all the wall layers. Following parallel tunnel creation, the cricopharyngeal septum is divided again to the base of the diverticulum as best as one can tell, and then the mucosal incision is then closed, most commonly with standard hemoclips. However, you can use other devices such as endoscopic tacking or endoscopic suturing. One thing to keep in mind, if you look at panel F, while this schematic shows that the diverticular pouch has kind of resolved, that may not tell the whole story. Sometimes you do end up with a mucosal septum that, in my view, will stretch out and conform to the scaffolding below over time. But in the immediate sense, it may persist. It certainly doesn't have the muscular scaffolding that it did prior to the myotomy, but just keep in mind that your visual appearance after a Z-POM may not be all that different than it is pre-POM. Functionally, I'm not sure that that matters for the patient, and if you need to do a repeat procedure, essentially you're just cutting a mucosal bridge, which has a low likelihood to cause any sort of adverse events. So here we'll show a short video of a Z-POM. So there's the mucosal blub we're incising. This is tunneling down the true esophageal lumen. Actually, that's a lie. That's the diverticular lumen. You can see what I mean. You come out into free space, and it's very disconcerting, but that is what it looks like. Now we're dissecting down the true esophageal side, and you see submucosal dissection is similar to any other kind of POEM approach. We re-enter the tunnel. You're able to see the cricopharyngeal septum and the two lumens, and then the cricopharyngeal septum is divided. Typically, for settings, I'll use, for tunneling, I will use a spray coagulation, sometimes swift coagulation on the Irby generator, and then for myotomy, typically, I will use either spray. This is spray here, or Endocut I 50-in-2, and then that's at what I believe is the base, and then here we see closure with a couple of hemo clips. Typically, for closure, the mucosotomy, you end up using between three and five clips. This can be a bit challenging. Also, keep in mind, this is very high in the esophagus, almost in the back of the throat, so you want to make sure those clips are very secure prior to deployment. Knock on wood, I have not had a patient who called after they spit out a clip, but it definitely is something that all of us get concerned about, so you just want to make sure that the clips are in good position. I don't generally, with either approach, get a post-procedure esophagram. Depending on the patient, I may admit them to the hospital, but I don't generally get an esophagram unless there's some concern or symptoms or fever or pain or something like that. Typically, let patients have clear liquids on first day and slowly advance them to a normal diet over a few days. So, when you think about Z-POM, the advantages over the conventional approach, potentially improve visualization, procedural control. Again, you can isolate the muscle, that part is true. I do think it's easier to identify the base of the diverticulum, certainly with less bleeding. Preservation of the mucosa is a huge benefit as this is your first barrier to infection or leak. And then, I'm a little bit more liberal with dietary advancement using the Z-POM approach compared with a conventional myotomy. In terms of the disadvantages, it's a very, very tight working space and it's high in the esophagus. Again, closure can be challenging. It's doable, but it can be challenging. You know, going back to what I mentioned about kind of that mucosa on mucosa bridge that can happen, that tends to happen in patients with a large diverticulum. Again, whether it's symptomatic or causes an issue is hard to know, but you can have definitely retention within that pouch. So, a second procedure may be indicated. The same can be said for the conventional flexible endoscopic CP myotomy. My view is that if I leave a little bit of the diverticulum behind and I need to come back and cut more, that's a better outcome for the patient than having a perforation for cutting just a little bit too much. So, I don't think having to come back and do a little cleanup work should be frowned upon. I think, you know, that's, like I said, a much better approach than a perforation. Here you can see a pretty sizable diverticulum, which would be, you know, a long Z poem, potentially at risk for a multistage procedure or persistent symptoms requiring a second look at least. All right, so we'll talk about Killian-Jameson diverticulum. So, this is actually a true esophageal diverticulum. It has all wall layers. It is unilateral. It can be bilateral in a quarter of the cases. Symptoms, diagnosis, essentially identical to a Zenker's. So, the Killian-Jameson diverticulum is below the UES, whereas the Zenker's is above. And in theory, this would be a decreased aspiration risk. I don't know if that's totally true, but in theory, that's positive. Surgical intervention is very similar to the Zenker's approach. The endoscopic options are also identical. There's certainly case reports of a transmural septum division, as well as a poem style approach. One important point to note, particularly from an endoscopic perspective, is that the recurrent laryngeal nerve enters the pharynx near the base of where a Killian-Jameson diverticulum is. So, extreme care must be taken when doing an endoscopic procedure on these patients, because you're probably not going to see that nerve until it's too late, or maybe not at all. And that can result in permanent hoarseness for the patient as an adverse event. So, when you compare Killian-Jameson to Zenker's, Killian-Jameson tend to be anterolateral and below the cricopharyngeus, whereas Zenker's tend to be posterior wall and above the cricopharyngeus. There was a recent case report, many of you may have seen, about a very, very large Killian-Jameson, that even during physical exam, when the patient had deep expiration, the neck, you know, there was huge neck bulge anteriorly. So, that's kind of your way to discern between the two when doing any sort of intervention or diagnosis. So, here's just a picture. This isn't a video. The device being used here is a clutch cutter. And again, the techniques and the approach are the same, to divide the septum down the middle, creating a common channel. Again, the biggest concern with this is just where that recurrent laryngeal nerve inserts. But the technical approaches are nearly identical. So, skipping on to mitosophageal diverticulum, sometimes known as a traction diverticulum. Surgical intervention remains, you know, the mainstay of treatment for these. These tend to develop due to local inflammation of the pleura or the lung that creates basically tethering, and thereby, over time, a diverticulum. Endoscopic septum division, or POEM, have been described, but it must be kept in mind that the septum wall is not a muscular wall. So, as you divide, if you look at the kind of the B picture to the right, that's a very thin wall. And doing a septotomy there, you don't quite know what's in between. If the diverticulum is completely adherent to the esophageal wall, then you'll probably get away with it and everything will be fine. If it's not completely adherent, then essentially you're creating a mediastinal perforation, and now we have a big problem. Again, intervention would be purely based on symptoms. In the very limited patients I've seen with a mitosophageal diverticulum, their symptoms are often regurgitation, occasionally adenophagia or dysphagia. But more frequently, the diverticulum gets kind of packed with food and patients have significant regurgitation. Surgically, here you can see in panel A, the diverticulum, and then in panel B, resection of the diverticulum with a distal myotomy. There's less evidence to suggest that a mitosophageal diverticulum is related to a motility disturbance, particularly when compared to an epiphrenic diverticulum. So the myotomy is kind of a plus-minus. I don't think that that's a mandatory type situation where it is with the epiphrenics. But it tends to be a surgical approach when it comes to mid esophageal diverticulum, at least in most centers. So we'll finish up the last few minutes here before questions with epiphrenic diverticulum. This is a distal esophageal diverticulum that most commonly is related to esophageal dysmotility, which there's concomitant esophageal dysmotility in more than 60 or 70% of cases. It's a pretty rare finding, 0.2 to 0.8% prevalence. Historically, management has been surgical with an approach that includes diverticular resection or diverticulectomy followed by a, what amounts to a heller myotomy with a door fundoplication, or speaking more in a, you know, kind of straightforward sense, a distal myotomy, and then a partial wrap, a partial fundoplication. There have been some recent developments, case reports, small case series, where a poem type approach has been used, but again, the data is quite limited and certainly limited to case reports or small case series. So here on the left panel, you can see an esophagram. The blue arrow, just I marked to kind of show, clearly there's abnormal motility of the esophagus. I know that an esophagram is a very poor study for discerning dysmotility, but this is not normal, a normal esophagram by any means. At the yellow arrow, you can see a relatively large epiphrenic diverticulum with a relatively large mouth, and then distal to that at the red arrow, some high pressure zone from achalasia in this patient. This is the same patient on the right panel. The yellow arrow points towards this quite large epiphrenic diverticulum with a red arrow pointing down the true esophageal lumen. So this is just kind of a schematic of what would be surgery. This is a schematic I stole at the heller myotomy with a door fundal placation. Again, this would be done following a diverticular resection here in the distal esophagus. I'd like to finish or almost finish here with a video. It's a video actually published by Dr. Bala. Here, you can see we were just in the epiphrenic diverticulum. Again, diverticulum to the left, true lumen to the right. We do our submucosal injection. We treated this very similar to what we demonstrated earlier with the Zenker's poem approach. Here, we're using a hybrid T-knife and dissecting the true esophageal lumen, creating a submucosal tunnel. After creating a submucosal tunnel into the gastric cardia, we come back and we do what amounts to an esophageal poem. My general approach for esophageal poem is to expose the longitudinal fibers and then try to get my dissection knife in that plane between the circular and longitudinal fibers. Here, you see, I reach underneath, grab up and kind of cut chunks of circular fibers all at once. Following the esophageal myotomy, we dissect out the diverticular side. Again, keeping in mind that you go into this free space that's not totally normal. After the diverticulum is exposed, you can see here the septum between the esophagus and the epiphrenic diverticulum is exposed. And then we continue with the septum division. So the goal of this procedure is kind of twofold. Number one, to do a poem on the distal esophagus to improve food passage, and then a septotomy at the level of the diverticulum to hopefully limit retention of food and liquid within the diverticulum. So with that, we will conclude. Surgical and endoscopic management of various esophageal diverticula is safe and feasible. There are limited endoscopic options for mid-esophageal diverticula. However, there are both endoscopic and surgical options for other remaining esophageal diverticula. Submucosal myotomy of the muscular septum with or without distal esophageal myotomy is promising for many of these types of esophageal diverticula. One point I would make, again, mainly relating to Zenkers, since that's what all of us tend to see most commonly, is there really is no data suggesting superiority of the flexible endoscopic approach over the rigid endoscopic approach. Certainly there is data to suggest that either endoscopic approach is better, probably for patients, than an open transcervical diverticulectomy. There's several papers, including one recently from Thomas Runge that compares a flexible endoscopic approach to the transcervical diverticulectomy, and the transcervical diverticulectomy group is certainly a much more morbid procedure. So either of the endoscopic approaches can be reasonable. I don't think the ENT docs or interventional endoscopy, GI docs can say that one is better. However, there may be a better approach on a patient-by-patient basis. Certainly patients with limited neck flexion, cervical osteophytes, or the inability for placement of a rigid diverticuloscope would be more suited for a flexible approach. As I mentioned earlier, patients who have a very large diverticulum, in all reality, they may be best served by a surgical approach, as opposed to an endoscopic approach. But none of these things are well-defined in the available literature. Certainly a randomized trial or something along those lines, comparing the two would be welcome. So with that, I will conclude, and I'm happy to take any questions. Thanks, Dr. Law, for a great talk. We appreciate it. We actually do have several questions here, and so we're gonna get started. The first question is, is there any advantage or disadvantage to using a barium pill for an esophagram study? In the context of a diverticulum, I would say no. I think that the one area where the pill may help is, I guess, in the setting of a patient with epiphrenic diverticulum. And if you were trying to sort out if there was a distal esophageal stricture versus achalasia, it may be helpful. But all in all, I think you'll get the answer that you're looking for from a routine esophagram without a barium tablet. Great, thank you. So the next question is, in patients that have large Zanker's diverticuli, if they're asymptomatic, do you still feel that they need treatment? Absolutely not. If the patient is truly asymptomatic, meaning no regurgitation, nothing whatsoever, I would say that they do not need therapy. All right, next question here. For Zanker's diverticulum, can you comment on the newer approach with beginning injection at the level of the diverticular septum? Yeah, so this has actually been described a few times. Norio Fukami described it a few years back, and then more recently, Sawani Ngrumfang from Hopkins had described a small case series. And they kind of term it like a mucosal sparing diverticulotomy. I don't think that there's any harm in doing that. I presume what the question is being asked is literally injection of the diverticular septum, make a very small incision, just enough to get your scope in, and then divide the septum in front of you. Certainly a welcome approach. There's no downside per se to it. I think, again, it really comes down to endoscopist comfort, but that is a valid technique for sure. So the next question is, are biopsies indicated to evaluate for Crohn's disease in patients that have mid and distal esophageal diverticula? That's a tough question to answer. I would say in terms of routinely, when you just think of, in general, the rarity of a mid esophageal diverticulum, typically those occur more so with lung inflammation, pleurisy and so forth. I wouldn't say they're indicated. With that being said, there's definitely case reports out there of GI pathology within diverticula. I can think of several case reports of patients who've developed adenocarcinoma or squamous cell carcinoma within a diverticulum. So what I would say is that maybe not routinely biopsy, but certainly if you're able to intubate the diverticulum safely with your scope, it's certainly worth looking at the mucosa. Biopsying some of these pseudodiverticula, you have to be a little bit careful because the wall's pretty thin too. There is no muscular backing. So I think in certain contexts it's worthwhile. Certainly taking a look is worthwhile, but I don't know that I would say it's routinely indicated without a real good reason as to why. All right, we have another question here. If a referral comes in for a diverticulum, epiphrenic or distal, is manometry helpful or required, or would a poem always be performed with a diverticulectomy? A diverticulotomy, excuse me. Good question. So to me, manometry is helpful. While the vast majority of these patients will have some sort of motility disorder. Well, the only thing, the one caveat with this in the setting of epiphrenic diverticulum is you may want endoscopic placement of the manometry catheter versus blind placement because you don't want to perforate the diverticulum. So if I had my choice, I would do manometry in a patient with an epiphrenic diverticulum because I think it's useful information. More times than not, you will end up getting to the point where you need some sort of intervention, either endoscopic or surgical, because it will end up being a motility disturbance. But my preference would be to have more information if I could, so I would do a manometry. So you touched on some of your post-procedure recommendations after your Zanker's repairs, but do you give all your patients antibiotics during the procedure or after the procedure, or is it on a case-by-case basis? That's a good question. I generally, I always give a single dose during the procedure of a broad-spectrum antibiotic. Certainly, if I have any concerns about how the procedure went, I'll send patients home with three to five days of antibiotics. I don't do it on everybody, just like I don't admit everybody. I think if a patient is otherwise reasonably healthy, lives local to the hospital, feels good after the procedure, I think it's reasonable to send them home and advance their diet. But I definitely give a single pre-procedure dose. With that being said, and the same thing applies to other types of POEM procedures, there's no data to suggest that antibiotics actually prevent infection. And to do that study would require countless patients. So I think we all do it as a, we treat it as if it's holy water more than anything else, but I do think it's good practice, certainly for submucosal tunneling, to give us at least one single dose of IV broad-spectrum. I don't do, because the tunnels show short, typically in Z-POEM or some of these other diverticular POEMs, I don't do tunnel lavage with antibiotics like I do for esophageal POEM, but that's kind of my practice. All right, we can, another question here. So for trainees or physicians that are new to performing POEM or Z-POEM, how many POEM do you think are necessary prior to attempting a Z-POEM approach if someone's been using a conventional approach prior to that? That's also a good question. I would say it's probably on a person-by-person basis. I can tell you I didn't do my first Zenker's POEM probably until I had done, I don't know, maybe 40 or 50 conventional esophageal POEMs. Part of that's because it didn't, a case didn't come along, but the other part of it is comfort level. It is, while the techniques are similar, it is different. Like I said, you're working pretty high up in the esophagus, almost in the back of the throat. So I would say that even for people who are exceptionally skilled, make sure you're comfortable with the whole esophageal POEM approach before taking on any other tunneling procedures. That goes for gastric POEM too. Each of the kind of variants are different enough that you wanna be really confident and really comfortable with managing whatever comes your way. And by the time you get to 50 procedures, you've probably had a few tunnel bleeds during the procedure. You've probably had a mucosotomy or other things that you've had to kind of sort out. So I think that the more, the better. I definitely don't think that this is something that should be taken lightly. If there's a big problem in this area, it's high-end real estate, and it's going to be a significant issue for the patient. So I would say, the more, the better would be the best advice I could give. I think if we have time, we have one more question that just came in. So after Z-POEM, have you experienced patients describing throat discomfort? And if so, do you think this is related to the clip placement? Yeah, I mean, my experience has been all patients have a little bit of throat discomfort. I have not ever attributed it to clip placement. I think it's more likely related to, you know, the immediate inflammation from dissecting, you know, the diverticulum than anything else. And to me, that's the reason how I've kind of rectified things that way is that, you know, if you call those same patients back 24 hours to 48 hours later, they have much less throat pain, but the clips are still there. So anything related to the clips, I would expect would be a persistent, you know, pain as opposed to a short-lived pain. So no, I don't attribute it to the clips. You know, I take pause every time I put clips that high up to make sure they're well seated, but to be fair, other closure modalities in that, working in that space are more difficult like suturing or endoscopic tacking with some of the newer tacking devices. So I think it's still the best approach, particularly in the throat. One thing that I prefer in the esophagus as well as for the Zenkers is I prefer to use a clip that has a short tail on it. So if you look at like a Microtech clip, some of the newer Olympus clips, the Cook Instant clip, for example, not to support any one of those other than currently available clips, but in this indication, I like to have a really short tail to try and minimize any possibility that those clips are causing any irritation. All right, I think we're at the top of our hour. Are there any other questions or comments, Dr. Hathorn, Dr. Bala? Are we good? All right. It was an awesome presentation and discussion tonight. Dr. Hathorn, Dr. Bala, thank you for facilitating the questions. Congratulations to the both of you for completing your fourth year fellowship and all the best to you as you embark on your careers. Thank you. In closing, I wanna also thank everybody that's on the webinar tonight for your participation in tonight's discussion with Dr. Law. So this also concludes our presentation. We hope the information tonight has been useful to you and to your GI and endoscopy practice. Just as a quick reminder, you can access a recording of this webinar by logging onto GILeap by going to learn.asge.org. You do not have to be an ASGE member to access this content as our goal at ASGE is to provide this information and the education from our Thursday webinar topics. That's an open source resource to all gastroenterologists globally in improving their practices. And just one final reminder before we conclude is that our next webinar will be next Thursday, July 1st at 7 p.m. That will be an endo hangout for GI fellows and we'll have a great panel gathered together to discuss job searching and contract negotiations part two. Our first part of this was actually a few weeks ago at the beginning of the month and we're gonna continue that discussion because of the feedback that we received. So please plan to attend. Thank you again and have a wonderful rest of your evening.

Esophageal diverticula

Zenker's diverticulum

Symptoms of esophageal diverticula

Esophageal cancer

Diagnosis of esophageal diverticula

Imaging studies for esophageal diverticula

Lab studies for esophageal diverticula

Surgical techniques for esophageal diverticula

Endoscopic techniques for esophageal diverticula

Types of esophageal diverticula