970 SUCCESSFUL SINGLE-SESSION CRICOPHARYNGEAL AND ZENKER’S DIVERTICULUM PER-ORAL ENDOSCOPIC MYOTOMY

Abstract

Therapy of symptomatic Zenker’s diverticulum (ZD) can be accomplished with open surgery, rigid endoscopy, or flexible endoscopy. Per-oral endoscopic myotomy (POEM) can be used to treat ZD using principles of submucosal tunneling. POEM has potential advantages over traditional endoscopic septotomy, including complete septum division and mucosal integrity during septotomy. It may be associated with decreased risk of symptom recurrence given complete exposure and dissection of the septum. A 94-year-old female with past medical history of hypertension and atrial fibrillation was referred for daily symptoms of solid and liquid food dysphagia and regurgitation, which occur with every meal. Patient denied weight loss and dyspnea. Barium esophagram revealed a 4 cm ZD. Decision was made to perform Zenker’s POEM. A diagnostic gastroscope was fitted with a clear 4mm straight cap. A tight cricopharyngeus muscle was noted at 17 cm from the incisors and then a large ZD was identified. The esophagus was washed with gentamicin (240mg in 240ml of sterile water). A mucosal bleb was created 2 cm above the cricopharyngeus muscle at 15 cm form the incisors by injection of a combination of saline, 1% indigo carmine and diluted epinephrine. A 1.5 cm incision was made with an ESD knife with triangular tip using electrosurgical current set at dry cut mode (50 W) at the posterior wall. The submucosal fibers were dissected with spray coagulation (40W) and the endoscope advanced to the submucosal space. A submucosal tunnel was created using spray coagulation and injection of saline/indigo carmine solution via the pump, from 15 to 22 cm. When vessels were identified they were treated using a grasper with soft coagulation setting. The ZD septum was identified. After the tunnel on the esophageal side of the septum was completed, the tunnel on the diverticular side was commenced and completed with exposure of the septum. Septotomy was then performed using a combination of an ESD knife with insulated tip and an ESD Knife with a triangular tip and spray coagulation current (50 W). After the completed septotomy, the tight cricopharyngeus muscle was identified and cricopharyngeal myotomy was performed using the ESD knife with insulated tip. This resulted in easy passage of the endoscope across the upper esophageal sphincter. Finally, the mucosal incision was securely closed using 6 through-the-scope clips. There were no complications and patient was admitted overnight. A CINE esophagram performed next day showed no leak. After 3 months post-POEM, there was compete resolution of symptoms with no dysphagia or regurgitation. POEM is safe and feasible to treat ZD and a hypertensive cricopharyngeus muscle during the same session. This technique has the advantage of complete septum division which may decrease the risk of symptoms recurrence.