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This multi-center international study evaluated the effectiveness of peroral endoscopic myotomy (Z-POEM) for treating Zenker's diverticulum. Z-POEM involves creating a submucosal tunnel and completely dividing the septum between the esophagus and diverticulum. The study found Z-POEM had high clinical success rates of over 90% at 6 months with few complications. Recurrence rates were low. The researchers concluded Z-POEM is a safe and effective alternative to surgery for Zenker's diverticulum that allows for complete septal division. However, larger prospective studies are still needed.

Health & Medicine

R2 CG Erick Orlando Vásquez Cruz
Elkholy S, El-Sherbiny M, Delano-Alonso R, Herrera-Esquivel J de J, Valenzuela-Salazar C, Rodriguez-Parra A, et al. Peroral endoscopic myotomy as treatment for Zenker’s
diverticulum (Z-POEM): a multi-center international study. Esophagus [Internet]. 2021;18(3):693–9. Disponible en: http://dx.doi.org/10.1007/s10388-020-00809-7

Introduction.
“Zenker’s diverticulum (ZD) is a rare disorder characterized by
herniation of the mucosa and submucosa through Killian’s
triangle”.
ZD Elderly males 70s
Etiology Uknown
Incressed pressure
Elkholy S, El-Sherbiny M, Delano-Alonso R, Herrera-Esquivel J de J, Valenzuela-Salazar C, Rodriguez-Parra A, et al. Peroral endoscopic myotomy as treatment for Zenker’s
diverticulum (Z-POEM): a multi-center international study. Esophagus [Internet]. 2021;18(3):693–9. Disponible en: http://dx.doi.org/10.1007/s10388-020-00809-7

Symptoms
Regurgitation
Halitosis
Dysphagia
Cough
Recurrent aspiration
Elkholy S, El-Sherbiny M, Delano-Alonso R, Herrera-Esquivel J de J, Valenzuela-Salazar C, Rodriguez-Parra A, et al. Peroral endoscopic myotomy as treatment for Zenker’s
diverticulum (Z-POEM): a multi-center international study. Esophagus [Internet]. 2021;18(3):693–9. Disponible en: http://dx.doi.org/10.1007/s10388-020-00809-7

Treatment
• Surgical correction: invasive procedure
• Morbidity 2.5 – 46%
• Mortality 0–2.3%
• Endoscopic intervention : less invasive alternative
• Incision through the septum to connect the diverticulum to the
esophageal lumen.
• Perforation / incomplete cutting
• Shorter operative and recovery times.
Elkholy S, El-Sherbiny M, Delano-Alonso R, Herrera-Esquivel J de J, Valenzuela-Salazar C, Rodriguez-Parra A, et al. Peroral endoscopic myotomy as treatment for Zenker’s
diverticulum (Z-POEM): a multi-center international study. Esophagus [Internet]. 2021;18(3):693–9. Disponible en: http://dx.doi.org/10.1007/s10388-020-00809-7

• Outcomes associated with endoscopic septotomy; success
rates are typically between 56 and 100%
• Symptoms recurring in 10–35%
• Recurrence had been attributed to incomplete division of the
septum.
Elkholy S, El-Sherbiny M, Delano-Alonso R, Herrera-Esquivel J de J, Valenzuela-Salazar C, Rodriguez-Parra A, et al. Peroral endoscopic myotomy as treatment for Zenker’s
diverticulum (Z-POEM): a multi-center international study. Esophagus [Internet]. 2021;18(3):693–9. Disponible en: http://dx.doi.org/10.1007/s10388-020-00809-7

• Peroral endoscopic myotomy (POEM) was first described for
the treatment of achalasia.
• It is currently used for the treatment of other gastrointestinal
diseases
• This technique creates a third space via submucosal tunneling
that results in the complete exposure and division of the
septum
Elkholy S, El-Sherbiny M, Delano-Alonso R, Herrera-Esquivel J de J, Valenzuela-Salazar C, Rodriguez-Parra A, et al. Peroral endoscopic myotomy as treatment for Zenker’s
diverticulum (Z-POEM): a multi-center international study. Esophagus [Internet]. 2021;18(3):693–9. Disponible en: http://dx.doi.org/10.1007/s10388-020-00809-7

• POEM has been applied for the treatment of ZD (Z-POEM).
• Submucosal endoscopy facilitates complete visualization and
division of the septum.
• Initial studies featuring Z-POEM reported promising results.
Elkholy S, El-Sherbiny M, Delano-Alonso R, Herrera-Esquivel J de J, Valenzuela-Salazar C, Rodriguez-Parra A, et al. Peroral endoscopic myotomy as treatment for Zenker’s
diverticulum (Z-POEM): a multi-center international study. Esophagus [Internet]. 2021;18(3):693–9. Disponible en: http://dx.doi.org/10.1007/s10388-020-00809-7

• Dx. Barium swallow
or CT.
• Confirmed. EC.
• Kotahari-Haber Score
International Multi-center
Retrospective
study
Five countries
J. 2018- D.
2019
Costa rica, Egypt, Mexico,
Lebanon, Turkey.

Elkholy S, El-Sherbiny M, Delano-Alonso R, Herrera-Esquivel J de J, Valenzuela-Salazar C, Rodriguez-Parra A, et al. Peroral endoscopic myotomy as treatment for Zenker’s
diverticulum (Z-POEM): a multi-center international study. Esophagus [Internet]. 2021;18(3):693–9. Disponible en: http://dx.doi.org/10.1007/s10388-020-00809-7

Z-POEM steps
• Step 1: Creation of the submucosal bleb just proximal to the
septum.
• Step 2: Creation of a tunnel opening of~1 cm in length.
• Step 3: Dissection on the esophageal and diverticular sides of
the septum to achieve complete exposure.
• Step 4: Complete division of the septum.
• Step 5: Extension of the myotomy by 1 cm into the esophageal
muscle to ensure complete division of the septum.
• Step 6: Closure of the tunnel opening using endoclips after
examination to rule out any mucosal injuries. Short clips are
preferred to avoid foreign body sensation.
Elkholy S, El-Sherbiny M, Delano-Alonso R, Herrera-Esquivel J de J, Valenzuela-Salazar C, Rodriguez-Parra A, et al. Peroral endoscopic myotomy as treatment for Zenker’s
diverticulum (Z-POEM): a multi-center international study. Esophagus [Internet]. 2021;18(3):693–9. Disponible en: http://dx.doi.org/10.1007/s10388-020-00809-7

Follow-up and study outcomes
• Patient follow-up occurred at fixed intervals of 6, 12, 18, and
24 months.
• Follow-up included assessments of clinical symptoms (Kothari-
Haber Score).
• Cinical success; Kothari-Haber Score < 2
• Kothari-Haber Score > 3 = Recurrence.
Elkholy S, El-Sherbiny M, Delano-Alonso R, Herrera-Esquivel J de J, Valenzuela-Salazar C, Rodriguez-Parra A, et al. Peroral endoscopic myotomy as treatment for Zenker’s
diverticulum (Z-POEM): a multi-center international study. Esophagus [Internet]. 2021;18(3):693–9. Disponible en: http://dx.doi.org/10.1007/s10388-020-00809-7

Results
Elkholy S, El-Sherbiny M, Delano-Alonso R, Herrera-Esquivel J de J, Valenzuela-Salazar C, Rodriguez-Parra A, et al. Peroral endoscopic myotomy as treatment for Zenker’s
diverticulum (Z-POEM): a multi-center international study. Esophagus [Internet]. 2021;18(3):693–9. Disponible en: http://dx.doi.org/10.1007/s10388-020-00809-7

Conclusion
• Z-POEM is a safe, efective, and ingenious solution for the
management of ZD that successfully overcomes the risk of
surgery and the drawbacks of conventional endoscopic
septotomy
Elkholy S, El-Sherbiny M, Delano-Alonso R, Herrera-Esquivel J de J, Valenzuela-Salazar C, Rodriguez-Parra A, et al. Peroral endoscopic myotomy as treatment for Zenker’s
diverticulum (Z-POEM): a multi-center international study. Esophagus [Internet]. 2021;18(3):693–9. Disponible en: http://dx.doi.org/10.1007/s10388-020-00809-7

• Retrospective analysis and the lack of long-term follow-up are
the main limitations f this study. Wider prospective studies are
needed for true evaluation of Z-POEM and comparing it with
other modalities.
Elkholy S, El-Sherbiny M, Delano-Alonso R, Herrera-Esquivel J de J, Valenzuela-Salazar C, Rodriguez-Parra A, et al. Peroral endoscopic myotomy as treatment for Zenker’s
diverticulum (Z-POEM): a multi-center international study. Esophagus [Internet]. 2021;18(3):693–9. Disponible en: http://dx.doi.org/10.1007/s10388-020-00809-7

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Z-POEM.pptx

1. R2 CG Erick Orlando Vásquez Cruz Elkholy S, El-Sherbiny M, Delano-Alonso R, Herrera-Esquivel J de J, Valenzuela-Salazar C, Rodriguez-Parra A, et al. Peroral endoscopic myotomy as treatment for Zenker’s diverticulum (Z-POEM): a multi-center international study. Esophagus [Internet]. 2021;18(3):693–9. Disponible en: http://dx.doi.org/10.1007/s10388-020-00809-7

2. Introduction. “Zenker’s diverticulum (ZD) is a rare disorder characterized by herniation of the mucosa and submucosa through Killian’s triangle”. ZD Elderly males 70s Etiology Uknown Incressed pressure Elkholy S, El-Sherbiny M, Delano-Alonso R, Herrera-Esquivel J de J, Valenzuela-Salazar C, Rodriguez-Parra A, et al. Peroral endoscopic myotomy as treatment for Zenker’s diverticulum (Z-POEM): a multi-center international study. Esophagus [Internet]. 2021;18(3):693–9. Disponible en: http://dx.doi.org/10.1007/s10388-020-00809-7

3. Symptoms Regurgitation Halitosis Dysphagia Cough Recurrent aspiration Elkholy S, El-Sherbiny M, Delano-Alonso R, Herrera-Esquivel J de J, Valenzuela-Salazar C, Rodriguez-Parra A, et al. Peroral endoscopic myotomy as treatment for Zenker’s diverticulum (Z-POEM): a multi-center international study. Esophagus [Internet]. 2021;18(3):693–9. Disponible en: http://dx.doi.org/10.1007/s10388-020-00809-7

4. Treatment • Surgical correction: invasive procedure • Morbidity 2.5 – 46% • Mortality 0–2.3% • Endoscopic intervention : less invasive alternative • Incision through the septum to connect the diverticulum to the esophageal lumen. • Perforation / incomplete cutting • Shorter operative and recovery times. Elkholy S, El-Sherbiny M, Delano-Alonso R, Herrera-Esquivel J de J, Valenzuela-Salazar C, Rodriguez-Parra A, et al. Peroral endoscopic myotomy as treatment for Zenker’s diverticulum (Z-POEM): a multi-center international study. Esophagus [Internet]. 2021;18(3):693–9. Disponible en: http://dx.doi.org/10.1007/s10388-020-00809-7

5. • Outcomes associated with endoscopic septotomy; success rates are typically between 56 and 100% • Symptoms recurring in 10–35% • Recurrence had been attributed to incomplete division of the septum. Elkholy S, El-Sherbiny M, Delano-Alonso R, Herrera-Esquivel J de J, Valenzuela-Salazar C, Rodriguez-Parra A, et al. Peroral endoscopic myotomy as treatment for Zenker’s diverticulum (Z-POEM): a multi-center international study. Esophagus [Internet]. 2021;18(3):693–9. Disponible en: http://dx.doi.org/10.1007/s10388-020-00809-7

6. • Peroral endoscopic myotomy (POEM) was first described for the treatment of achalasia. • It is currently used for the treatment of other gastrointestinal diseases • This technique creates a third space via submucosal tunneling that results in the complete exposure and division of the septum Elkholy S, El-Sherbiny M, Delano-Alonso R, Herrera-Esquivel J de J, Valenzuela-Salazar C, Rodriguez-Parra A, et al. Peroral endoscopic myotomy as treatment for Zenker’s diverticulum (Z-POEM): a multi-center international study. Esophagus [Internet]. 2021;18(3):693–9. Disponible en: http://dx.doi.org/10.1007/s10388-020-00809-7

7. • POEM has been applied for the treatment of ZD (Z-POEM). • Submucosal endoscopy facilitates complete visualization and division of the septum. • Initial studies featuring Z-POEM reported promising results. Elkholy S, El-Sherbiny M, Delano-Alonso R, Herrera-Esquivel J de J, Valenzuela-Salazar C, Rodriguez-Parra A, et al. Peroral endoscopic myotomy as treatment for Zenker’s diverticulum (Z-POEM): a multi-center international study. Esophagus [Internet]. 2021;18(3):693–9. Disponible en: http://dx.doi.org/10.1007/s10388-020-00809-7

8. • Dx. Barium swallow or CT. • Confirmed. EC. • Kotahari-Haber Score International Multi-center Retrospective study Five countries J. 2018- D. 2019 Costa rica, Egypt, Mexico, Lebanon, Turkey.

9. Elkholy S, El-Sherbiny M, Delano-Alonso R, Herrera-Esquivel J de J, Valenzuela-Salazar C, Rodriguez-Parra A, et al. Peroral endoscopic myotomy as treatment for Zenker’s diverticulum (Z-POEM): a multi-center international study. Esophagus [Internet]. 2021;18(3):693–9. Disponible en: http://dx.doi.org/10.1007/s10388-020-00809-7

10. Z-POEM steps • Step 1: Creation of the submucosal bleb just proximal to the septum. • Step 2: Creation of a tunnel opening of~1 cm in length. • Step 3: Dissection on the esophageal and diverticular sides of the septum to achieve complete exposure. • Step 4: Complete division of the septum. • Step 5: Extension of the myotomy by 1 cm into the esophageal muscle to ensure complete division of the septum. • Step 6: Closure of the tunnel opening using endoclips after examination to rule out any mucosal injuries. Short clips are preferred to avoid foreign body sensation. Elkholy S, El-Sherbiny M, Delano-Alonso R, Herrera-Esquivel J de J, Valenzuela-Salazar C, Rodriguez-Parra A, et al. Peroral endoscopic myotomy as treatment for Zenker’s diverticulum (Z-POEM): a multi-center international study. Esophagus [Internet]. 2021;18(3):693–9. Disponible en: http://dx.doi.org/10.1007/s10388-020-00809-7

11. Elkholy S, El-Sherbiny M, Delano-Alonso R, Herrera-Esquivel J de J, Valenzuela-Salazar C, Rodriguez-Parra A, et al. Peroral endoscopic myotomy as treatment for Zenker’s diverticulum (Z-POEM): a multi-center international study. Esophagus [Internet]. 2021;18(3):693–9. Disponible en: http://dx.doi.org/10.1007/s10388-020-00809-7

12. Follow-up and study outcomes • Patient follow-up occurred at fixed intervals of 6, 12, 18, and 24 months. • Follow-up included assessments of clinical symptoms (Kothari- Haber Score). • Cinical success; Kothari-Haber Score < 2 • Kothari-Haber Score > 3 = Recurrence. Elkholy S, El-Sherbiny M, Delano-Alonso R, Herrera-Esquivel J de J, Valenzuela-Salazar C, Rodriguez-Parra A, et al. Peroral endoscopic myotomy as treatment for Zenker’s diverticulum (Z-POEM): a multi-center international study. Esophagus [Internet]. 2021;18(3):693–9. Disponible en: http://dx.doi.org/10.1007/s10388-020-00809-7

13. Results Elkholy S, El-Sherbiny M, Delano-Alonso R, Herrera-Esquivel J de J, Valenzuela-Salazar C, Rodriguez-Parra A, et al. Peroral endoscopic myotomy as treatment for Zenker’s diverticulum (Z-POEM): a multi-center international study. Esophagus [Internet]. 2021;18(3):693–9. Disponible en: http://dx.doi.org/10.1007/s10388-020-00809-7

14. Elkholy S, El-Sherbiny M, Delano-Alonso R, Herrera-Esquivel J de J, Valenzuela-Salazar C, Rodriguez-Parra A, et al. Peroral endoscopic myotomy as treatment for Zenker’s diverticulum (Z-POEM): a multi-center international study. Esophagus [Internet]. 2021;18(3):693–9. Disponible en: http://dx.doi.org/10.1007/s10388-020-00809-7

15. Conclusion • Z-POEM is a safe, efective, and ingenious solution for the management of ZD that successfully overcomes the risk of surgery and the drawbacks of conventional endoscopic septotomy Elkholy S, El-Sherbiny M, Delano-Alonso R, Herrera-Esquivel J de J, Valenzuela-Salazar C, Rodriguez-Parra A, et al. Peroral endoscopic myotomy as treatment for Zenker’s diverticulum (Z-POEM): a multi-center international study. Esophagus [Internet]. 2021;18(3):693–9. Disponible en: http://dx.doi.org/10.1007/s10388-020-00809-7

16. • Retrospective analysis and the lack of long-term follow-up are the main limitations f this study. Wider prospective studies are needed for true evaluation of Z-POEM and comparing it with other modalities. Elkholy S, El-Sherbiny M, Delano-Alonso R, Herrera-Esquivel J de J, Valenzuela-Salazar C, Rodriguez-Parra A, et al. Peroral endoscopic myotomy as treatment for Zenker’s diverticulum (Z-POEM): a multi-center international study. Esophagus [Internet]. 2021;18(3):693–9. Disponible en: http://dx.doi.org/10.1007/s10388-020-00809-7

Z-POEM.pptx

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