Introduction

Several therapeutic modalities, including surgery, rigid and flexible endoscopy, have been described for the management of symptomatic Zenker's diverticulum (ZD). Symptom relief such as dysphagia and regurgitation constitute the primary goal of treatment. The ESGE (European Society of Gastrointestinal Endoscopy) recommends as first-line treatment the performance of a septotomy, which has a higher safety profile compared to Z POEM (Zenker's Peroral Endoscopic Myotomy). Septotomy is most commonly performed using a dissection knife or a needle knife, stopping the section 5 mm from the bottom of the diverticulum, leaving muscle fibers intact, which may contribute to some of the recurrences in the medium and long term. The aim of this retrospective study was to evaluate the safety and efficacy at 12 months of complete myotomy of the diverticular septum using a dissection scissor.

Aims & Methods

A septotomy with sectioning of the cricopharyngeal muscle fibers was performed in 43 patients presenting with a symptomatic Zenker's diverticulum of the upper third of the esophagus using the following technique: After oro-tracheal intubation in a patient lying supine, gastroscopy with a single-channel gastroscope equipped with a transparent hood was performed. Once the hood was positioned over the septum, an incision with a clutch cutter (Fujifilm) was made at two points on the diverticular wall, 5 mm apart, extending 2 mm into the mucosa and submucosa.
The next step involved avulsion of the mucosal and submucosal hood using a 10 mm diathermic loop by mucosectomy without injection to expose the cricopharyngeal muscle. Subsequently, complete sectioning of all muscle fibers using the clutch cutter under traction, followed by closure of the defect along its entire height using clips, was performed .
The symptoms were analyzed before the intervention as well as at 3, 6 months, and 1-year post-intervention using a comprehensive questionnaire with each patient serving as their own control before and after the procedure.
The following data were collected: peri- and post-procedural complications (hemorrhage, perforation, infection, others), procedure duration, immediate technical success, and clinical success at 3 months, 6 months, and 1 year.

Results

The average size of the Zenker's diverticulum was 25.6 mm, and the average procedure duration was 48 minutes.
No peri- or post-procedural complications were observed, although one patient experienced an injury to the piriform sinus. Patient follow-up was conducted at 3, 6, and 12 months post-intervention. During follow-up consultations, patients assessed the improvement of their symptoms as a percentage.
At 3 months, 92% of patients experienced a 100% improvement in their preoperative symptoms. By 6 months, 94% of patients reported a 100% improvement, which further increased to 97% at 12 months.
This series, the largest ever reported of complete cricopharyngeal myotomy using the Clutch cutter with complete closure of the defect, achieves an equivalent of "open" Z POEM without detachment of the cervical or mediastinal adipose spaces, with very low morbidity and a recurrence rate lower than that of classical septotomy.

Conclusion

The technique of complete cricopharyngeal muscle sectioning using the Clutch Cutter dissection tool is safe, effective, and associated with low morbidity, along with a very low recurrence rate at one year. It could potentially be considered as a first-line treatment for symptomatic Zenker's diverticula in patients who have not undergone prior treatment.

Disclosure

I can affirm that there is no conflict of interest associated with the study I conducted.