Counter mucosal incision with Zenker's peroral endoscopic myotomy: an innovative approach for mucosal decompression in Zenker's diverticulum and mucosal webs.

BACKGROUND AND AIMS

Zenker's diverticulum (ZD) is a pouch of the mucosa arising from the Killian triangle. Any size of symptomatic ZD or medium to large (2-3 cm or more) ZD needs intervention. Zenker's peroral endoscopic myotomy (Z-POEM) is the ideal first-line therapy for making the reliable myotomy. We aimed to demonstrate the latest Z-POEM techniques and counter mucosal incision (CMI) for a patient with larger-sized ZD and pre-existing esophageal mucosal webs near ZD.

METHODS

The CMI technique recently was developed by our hospital for antireflux intervention. It is a novel tension-relief technique of the mucosal plasty for enhancing closure stability. This time we performed esophageal mucosal incision on the opposite side of the Z-POEM defect closure part to relieve the mucosal tension and alleviate a postoperative stricture resulting from the tight clip closure in the background of the stiff surrounding mucosa and webs near the ZD.

RESULTS

We obtained complete eradication of ZD pouch without creating a stricture.

CONCLUSIONS

CMI is the ideal approach for preventing a stricture related to the use of tight clip closure of the Z-POEM for a larger-sized ZD with a background of the surrounding mucosal webs.