Successful advanced third-space endoscopic surgery by per-oral endoscopic myotomy (Z-POEM) for Zenker’s diverticulum: A case report and review of literature

INTRODUCTION: Zenker’s diverticulum is a rare condition caused by herniation of the mucosa at the pharyngoesophageal junction, resulting in dysphagia. Third-space endoscopic surgery now plays an important role in its management, facilitating precise surgery with good outcomes. The aim of report is to demonstrate technical steps and outcomes of per-oral endoscopic myotomy (Z-POEM). PRESENTATION OF CASE: We report two male patients presented with dysphagia. Esophagograms revealed Zenker’s diverticula of 2.1 and 2.0 cm, respectively, and diagnostic gastroscopy showed the diverticula to be 17 cm from the incisors, with tight, thick septal muscle. A 2-cm mucosal incision was made with a triangle-tipped knife, and submucosal tunneling was created by spray coagulation. The gastroscope was advanced into the submucosal space of the esophageal lumen and the diverticulum site until the bottom of the diverticulum could be clearly identified. The septal muscle was completely divided, immediately allowing the gastroscope to pass through easily, and the mucosal defect was reapproximated with hemoclips. DISCUSSION: As compared Z-POEM to previous technique; endoscopic septotomy, staple-assisted diverticulotomy, or open neck surgery, Z-POEM is less recurrent of symptoms and complications. Different types of endoscopic knife and lifting materials were used, but all provided the same outcomes. Most of the cases use though-the-scope clips to close the mucosal defect. CONCLUSION: Z-POEM provided precise treatment and complete view of the entire septal muscle can helps to avoid inadequate myotomy.