Zhang Linda Y, Nieto Jose, Ngamruengphong Saowanee, Repici Alessandro, Khashab Mouen A
Johns Hopkins Medical Institutions, Baltimore, Maryland.
Borland Groover Clinic, Jacksonville, Florida.
VideoGIE. 2021 Sep 15;6(12):562-567. doi: 10.1016/j.vgie.2021.08.003. eCollection 2021 Dec.
Zenker's diverticulum (ZD) is attributed to a poorly compliant cricopharyngeus muscle, and the mainstay of treatment is a cricopharyngeal myotomy. We present a video series summarizing endoscopic treatment options for ZD and related conditions.
We review the rationale and key technique for various endoscopic treatment modalities for ZD, cricopharyngeal bar, and other esophageal diverticula.
Standard flexible endoscopic cricopharyngeal myotomy involves the division of the common wall or septum of the ZD, aiming for complete transection of the cricopharyngeus. However, recurrence rates are high, likely owing to incomplete myotomy. Zenker's peroral endoscopic myotomy (Z-POEM) uses a proximal submucosal tunnel to provide direct visualization of the cricopharyngeus and septum, allowing confirmation of complete myotomy. We demonstrate an over-the-septum modification to simplify the technique. Submucosal fibrosis, commonly seen in patients with prior treatment, limits submucosal dissection. We present a hybrid technique to overcome this, whereby a traditional septotomy is performed until submucosal tissue is visualized. The intact mucosal flap after Z-POEM in a large ZD may contribute to residual dysphagia. We propose Z-POEM with mucosotomy for large ZD. Finally, we demonstrate modifications for treatment of other esophageal diseases, including cricopharyngeal bar and non-Zenker's esophageal diverticula.
Endoscopic treatment options for ZD and related conditions are rapidly expanding. With careful tailoring to individual patient characteristics, our expanding arsenal of options allows effective and safe treatment of a broad spectrum of patients.
Zenker憩室（ZD）归因于环咽肌顺应性差，治疗的主要方法是环咽肌切开术。我们展示了一系列视频，总结了ZD及相关病症的内镜治疗选择。
我们回顾了ZD、环咽肌条及其他食管憩室的各种内镜治疗方式的原理和关键技术。
标准的软性内镜环咽肌切开术包括切开ZD的共同壁或隔膜，目标是完全横断环咽肌。然而，复发率很高，可能是由于肌切开不完全。Zenker经口内镜肌切开术（Z-POEM）使用近端黏膜下隧道来直接观察环咽肌和隔膜，从而确认肌切开是否完全。我们展示了一种经隔膜改良方法以简化该技术。黏膜下纤维化常见于既往接受过治疗的患者，会限制黏膜下剥离。我们提出一种混合技术来克服这一问题，即先进行传统的隔膜切开术，直到可见黏膜下组织。大ZD患者行Z-POEM后完整的黏膜瓣可能导致残留吞咽困难。我们建议对大ZD行Z-POEM联合黏膜切开术。最后，我们展示了针对其他食管疾病（包括环咽肌条和非Zenker食管憩室）的治疗改良方法。
ZD及相关病症的内镜治疗选择正在迅速扩展。通过根据个体患者特征进行精心调整，我们不断扩充的选择手段能够有效且安全地治疗广泛的患者群体。
