S4174 Open Zenker’s Peroral Endoscopic Myotomy for Large Zenker's Diverticulum—Does It Retract the Sac?

Introduction: Recently, a modified approach of standard Zenker’s peroral endoscopic myotomy (Z-POEM) has been proposed called the open Z-POEM wherein mucosotomy is extended till the distal end of septotomy and proximally into the diverticular side and the wound is left open to cause sac retraction and disappearance of mucosal flap. Here, we share our experience of open Z-POEM. Case Description/Methods: A 60-year-old woman presented with a sensation of food getting stuck in her throat for 8 months. It was sudden onset, intermittent, progressive involving solid food. Her general and systemic examination was unremarkable. Her complete hemogram and biochemical profile were within normal limits. Her esophagogastroduodenoscopy revealed a large pouch containing food in the post-cricoid area and a hill’s grade 1 hiatus hernia. Her barium swallow showed a well-defined contrast-filled outpouching arising from the posterior wall of the cervical esophagus measuring 4 cm × 4.8 cm suggestive of Zenker’s diverticulum. She was given an option of surgery and open Z-POEM and she opted for the latter and gave her consent for open ZPOEM. The procedure was performed under general anesthesia with the patient in the supine position. A mucosal bleb was created on the septum and a 2 cm incision was given over the bleb. The submucosal space was entered and tunneling was done on the diverticular and the esophageal side. This was followed by a complete septotomy to the base of the diverticulum and its extension for 2 cm into the esophageal side. Following this, the mucosotomy was extended till the end of the septotomy and proximally into the diverticular side. After thorough hemostasis the wound was left open and a ryles tube was placed. Postoperative day 2 a conray study didn’t show any leak and the patient was started on oral liquids for 1 week. After 2 weeks the patient was advised to take a normal diet. With a follow-up of 2 ½ months, the patient is asymptomatic, however, her barium swallow this time showed increase in the size of the residual sac although with a free passage of contrast. Discussion: In the original description of open Z-POEM the authors have shown complete retraction of the sac at 6 months. On the contrary in our case, there was an increase in the size of the sac at 2 and a half months although the patient is doing well. Our case confirms the feasibility and safety of open Z-POEM. However, more follow-up would be needed to see whether the sac retracts or the patient becomes symptomatic again. Watch the video: https://tinyurl.com/25ACGS4174