Per‐oral endoscopic myotomy as treatment for Killian–Jamieson diverticulum

Abstract

Killian–Jamieson diverticulum (KJD) is a rare type of esophageal diverticulum less commonly encountered compared with Zenker's diverticulum (ZD). Endoscopic approach for these diverticula has been rapidly evolving. Currently, a flexible endoscopic septum division is considered the first‐line treatment for symptomatic ZD patients, however reported recurrence rates are over 10% according to recent literature. With the advent of submucosal tunneling technique established by per‐oral endoscopic myotomy for achalasia, it has been applied to treat ZD named as Zenker's diverticulum per‐oral endoscopic myotomy (Z‐POEM) as a minimally invasive treatment. Although there are very few reports utilizing submucosal tunneling approach to KJD, we have opted to perform Z‐POEM in order to safely perform complete dissection of the muscle septum while maintaining mucosal integration. Due to the difficulty of anatomical location of KJD, we created mucosal incision and subsequent submucosal tunnel directly at the level of the septum as opposed to creating a submucosal tunnel few centimeters proximal to the septum as being previously proposed. We report a case in which this technique was successfully performed with complete resolution of dysphagia without any adverse event. This technique permits to perform complete myotomies without the fear of causing perforation. Although larger cohorts are required to assess its safety and efficacy, Z‐POEM to treat KJD seems to be promising.

Evolving field of third‐space endoscopy: Derivatives of peroral endoscopic myotomy

“…These techniques have also been successfully applied to the Killian-Jamieson diverticulum by our group. 46 Z-POEM results in a high clinical success rate and low clinical recurrence rate. 38 In addition, with complete mucosal closure, adverse events, such as postoperative leakage or infection, are low.…”

“…POES is performed by incising the mucosa directly on top of the septum allowing direct access to the septum muscle fibers without the need for tunneling from the proximal side (Figs 5,6). These techniques have also been successfully applied to the Killian–Jamieson diverticulum by our group 46 . Z‐POEM results in a high clinical success rate and low clinical recurrence rate 38 .…”

Upper Gastrointestinal Endoscopy for Screening or Surveillance: Complication Avoidance and a Closer Look at the Esophagus

“…Surgery can be considered for the management of Zenker's diverticulum. However, the current first-line treatment involves cutting the entire septum and creating a common cavity between the esophagus and the diverticulum [45]. There are two methods of endoscopic septum division.…”

“…The second is Zenker's diverticulum per-oral endoscopic myotomy, which entails minimal mucosal incision to advance the endoscope into the submucosal space of the septum. Complete septotomy is then performed, and the mucosal incision site is securely closed with several endoclips [45].…”

POEM from A to Z: current perspectives

“…Surgery, even in minimally invasive variants such as thoracoscopy or laparoscopy, is associated with high morbidity (8%-23% risk of leaks or fistulas) and mortality (0%-7%) (18), which justifies the growing interest in using thirdspace endoscopy procedures. Most studies have evaluated the outcomes of diverticular POEM (D-POEM) for epiphrenic diverticula (EPD) (11,19), although case reports treating mid-esophageal (20) and Killian-Jamieson diverticula have also been published (21).…”