Zenker’s Peroral Endoscopic Myotomy (Z-POEM) is a minimally invasive, endoscopic procedure for the treatment of Zenker diverticulum. Here’s a step-by-step guide to help you successfully perform your first Z-POEM.
Step 1: Patient Selection
Ideal candidates: Patients with symptomatic Zenker diverticulum, particularly those with significant dysphagia or recurrent aspiration.
Exclude patients with contraindications to endoscopy or severe comorbidities.
Step 2: Preparation
Equipment:
Diagnostic gastroscope (Olympus EVIS X1, GIF 190) with a soft distal cap (Fuji DH-28GR).
Electrocautery device: ESG-300 (Olympus, Tokyo, Japan) with the following setting: PulseCut Fast 100W, Effect 2 and ForcedCoag 40W, Effect 2 for both incision / myotomy and dissection
Dissection knife: DualKnife (Olympus, Tokyo, Japan).
Carbon dioxide insufflator.
Hemostatic clips for mucosal closure.
Patient positioning: Left lateral decubitus under general anesthesia with endotracheal intubation.
Administer prophylactic antibiotics to reduce the risk of mediastinitis.
Step 3: Entry to the Submucosal Space
Mark the mucosa 2–3 cm proximal to the diverticular pouch.
Use the knife to create a longitudinal incision, exposing the submucosal layer.
Initiate submucosal tunneling using electrocautery, keeping the diverticular septum in view.
Step 4: Myotomy
Identify and dissect the cricopharyngeal muscle fibers along the diverticular septum.
Ensure complete myotomy without extending beyond the septum to avoid perforation.
Step 5: Mucosal Closure
Carefully close the mucosal entry with hemostatic clips to prevent leakage and expedite healing.
Step 6: Postoperative Care
Observe the patient for 24–48 hours to monitor for complications, such as perforation or infection.
Initiate a liquid diet, gradually advancing to solids as tolerated.
Tips and Tricks for Success
Use of submucosal injection: A combination of saline and blue methylene facilitates clear visualization of the layers.
Controlled dissection: Avoid excessive energy application to reduce thermal injury.
Manage bleeding promptly: Use coagulation forceps or hemostatic spray as needed.
Build confidence gradually: Start with smaller diverticula before tackling complex cases.
Potential Challenges
Bleeding: Be prepared with hemostatic tools (coag-grasper, etc.).
Perforation: Ensure meticulous technique and readiness for endoscopic closure.
Suboptimal visualization: Adjust cap position or use a water jet as necessary.
With the right preparation and practice, Z-POEM can become a safe and effective procedure in your therapeutic endoscopy repertoire!
