Single-tunnel Zenker's diverticulum peroral endoscopic myotomy.

Abstract

Zenker’s diverticulum peroral endoscopic myotomy (zPOEM) revolutionized the endoscopic treatment of Zenker’s diverticulum, since this is the only method that can provide deep myotomy [1]. Historically, the mucosal entrance was initially made in the hypopharynx, proximal to the septum. The procedure was recently modified [2], and many endoscopists have adapted this latest variation of mucosal entrance over the septum. In this video ([Video 1]), we present a new modification of this technique with the creation of a single tunnel instead of two. In particular, after mucosal incision over the septum ([Fig. 1]), a submucosal cushion is created at the esophageal side and a single tunnel is created at the side of the diverticulum ([Fig. 2], [Fig. 3]). Partial myotomy is performed, if necessary, to open the space for tunneling. Then, myotomy is performed through the diverticular tunnel ([Fig. 4], [Fig. 5]). This harbors the danger of damaging the esophageal mucosa. Therefore, repeated injections are provided at the submucosal space between the septum and the mucosa of the esophagus as needed. In our experience, this modification reduces the total duration of the procedure. The main potential drawback is the risk of inadvertent esophageal mucosal injury if the submucosal cushion is not sufficient.