UNVEILING THE UNSEALED: A MODEIFIED ZENKER'S PERORAL ENDOSCOPIC MYOTOMY WITH OPEN INCISION

Background: Peroral endoscopic myotomy for Zenker’s diverticulum (Z-POEM) has proven to be a safe treatment option with high technical and clinical success rates. However, the technique is associated with certain drawbacks including extended procedure duration and increased costs due to endoscopic clip usage for closure, as well as issues like redundant mucosa linked to clinical failure and recurrence. To overcome these limitations, we introduce a novel approach called Open Z-POEM. Endoscopic Methods: A novel technique was performed on 24 consecutive patients diagnosed with Zenker’s diverticulum (ZD), achieving 100% technical and clinical success at one-month follow-up. In this technique, an over-the-septum submucosal injection is performed, followed by mucosal incision and submucosal tunneling to fully expose the septal muscular layer. Subsequently, complete myotomy of both the diverticular and esophageal muscles are performed, ensuring the base of the prior ZD aligns with the level of the esophagus proper. Additionally, an extra 1-2 cm myotomy on the esophageal side is performed. Afterwards, mucosotomy of the remaining flap is executed distally on the esophageal side to 1-2 cm beyond the exposed esophageal muscle, and proximally from the initial mucosal incision to the base of the diverticulum. In large diverticula, where food stasis may result in submucosal fibrosis and adhesion of mucosa to the muscle, mucosotomy effectively ensures the removal of residual muscle tissue. Finally, the defect is left open and no clips are used for incision site closure. As submucosal tunneling is performed and the endoscopist is able to control any additional injury, the risk of perforation is minimal. Notably, the procedure has undergone refinements and enhancements over time. Key improvements include using a scissor-type knife for all aspects of the procedure, from mucosal incision to the final mucosotomy, and application of hemostatic gel at the defect site to promote healing and prevent bleeding. Conclusion: Open Z-POEM represents a modified and simplified Z-POEM approach. This method involves mucosotomy and remnant flap removal to potentially reduce recurrence rates. By leaving the defect open, this technique eliminates the challenges associated with mucosal closure, resulting in reduced procedure time and cost.