Background Treatment of Zenker’s diverticulum has evolved from open surgery to endoscopic techniques, including flexible and rigid endoscopic septotomy, and more recently, peroral endoscopic myotomy (Z-POEM). This study compared the effectiveness of flexible and rigid endoscopic septotomy with that of Z-POEM.
Methods Consecutive patients who underwent endoscopic septotomy (flexible/rigid) or Z-POEM for Zenker’s diverticulum between 1/2016 and 9/2019 were included. Primary outcomes were clinical success (decrease in Dakkak and Bennett dysphagia score to ≤ 1), clinical failure, and clinical recurrence. Secondary outcomes included technical success and rate/severity of adverse events.
Results 245 patients (110 females, mean age 72.63 years, standard deviation [SD] 12.37 years) from 12 centers were included. Z-POEM was the most common management modality (n = 119), followed by flexible (n = 86) and rigid (n = 40) endoscopic septotomy. Clinical success was 92.7 % for Z-POEM, 89.2 % for rigid septotomy, and 86.7 % for flexible septotomy (P = 0.26). Symptoms recurred in 24 patients (15 Z-POEM during a mean follow-up of 282.04 [SD 300.48] days, 6 flexible, 3 rigid [P = 0.47]). Adverse events occurred in 30.0 % rigid septotomy patients, 16.8 % Z-POEM patients, and 2.3 % flexible septotomy patients (P < 0.05).
Conclusions There was no difference in outcomes between the three treatment approaches for symptomatic Zenker’s diverticulum. Rigid endoscopic septotomy was associated with the highest rate of complications, while flexible endoscopic septotomy appeared to be the safest. Recurrence following Z-POEM was similar to flexible and rigid endoscopic septotomy. Prospective studies with long-term follow-up are required.
Background and Aim
Peroral endoscopic myotomy (POEM) is an established treatment for achalasia cardia (AC), however post-POEM gastroesophageal reflux (GER) remains a significant problem. Concomitant endoscopic fundoplication following POEM (POEM+F) was recently described to reduce post-POEM GER. This single-center study reports medium-term outcomes of POEM+F.
Patients and Methods
Retrospective analysis of prospectively maintained database of patients undergoing POEM+F. Abstracted data – demographics, achalasia type, pre-POEM Eckardt score (ES), prior therapy, follow-up. Follow-up was 3-monthly for one-year. Follow-up assessments included post-POEM ES, GerdQ score, EGD – wrap integrity and esophagitis, and pH studies. GER was defined according to Lyon consensus. Data was recorded as mean (SD) or median (IQR), P-value < 0.05 was considered statistically significant.
Results
25 patients underwent POEM+F, mean age (SD) – 40.13 (13.66) years, 12 females. POEM+F was technically successful in 23/25 (92%). Significant dysphagia improvement was seen in all 25 (mean [SD] pre- and post-POEM ES 8.21 [1.08] and 0.1 [0.3] respectively, p < 0.05). Mean total procedure and fundoplication time (SD) – 115.6 (27.2) and 46.7 (12.4) minutes respectively. Time reduced significantly after initial 5 cases. Median follow-up was 12-months (IQR 9 – 13). Intact wrap was seen in 19/23 (82.6%). GER (abnormal EAET) was seen in 2/18 (11.1%); one reported GerdQ > 8. Borderline GER (asymptomatic grade A esophagitis, normal EAET) was identified in 4/22 (18.1%). Two (8%) minor delayed adverse events required no intervention.
Conclusions
POEM+F is safe and reproducible. At 12-months follow-up, incidence of post-POEM+F GER was low and acceptable.
Introduction
Hirschsprung’s disease (HSCR) is congenital aganglionosis affecting hindgut and presents with constipation. Surgical pull-through is current standard but has morbidity. Per-rectal endoscopic myotomy (PREM) is a novel third space endoscopy technique for treating SS-HSCR.
Methods
Retrospective series of SS-HSCR patients diagnosed on history, contrast enema, rectal biopsies, anorectal manometry and treated by PREM. Aganglionic segment mapped pre-PREM. PREM performed using third space endoscopy principles. Objective – to compare stool frequency and unit laxative (UL) usage pre and post-PREM.
Results
N = 9; duration 4-years. Mean age – 7.5 (± 5.2) years; 7 males. Mean aganglionic segment length – 6.3 (± 4.4) cm. Mean procedure time – 96.1 (±37.9) minutes. Mean LOS – 2.5 (±0.7) days. Median follow-up –17 months (9 – 58). Stool frequency – pre – 1/4.4 (±1.5) vs. post – 1/1.2 (±0.4) days (p = 0.0004). Mean UL usage – pre – 5.4 (±4.9) vs. post – 0.4 (±0.7) units (p = 0.0002). No laxatives in 6 (66%). Single AE (anal stenosis) – dilatation.
Conclusions
PREM is a safe and effective minimally invasive procedure for SS-HSCR and provides long-term response.
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