Endoscopic mucosal incision and muscle interruption (MIMI) for the treatment of Zenker’s diverticulum

• Published in: Surgical endoscopy Vol. 35; no. 7; pp. 3896 - 3904
• Main Authors: Klingler, Michael J., Landreneau, Joshua P., Strong, Andrew T., Barajas-Gamboa, Juan S., Tat, Christine, Tu, Chao, Fathalizadeh, Alisan, Kroh, Matthew, Rodriguez, John, Sanaka, Madhusudhan R., Ponsky, Jeffrey
• Format: Journal Article
• Language: English
• Published: New York Springer US 01.07.2021; Springer Nature B.V
• Subjects: 2020 SAGES Oral; Abdominal Surgery; Dysphagia; Electronic health records; Endoscopy; Esophagus; Gastroenterology; General anesthesia; Gynecology; Hepatology; Medical records; Medicine; Medicine & Public Health; Patients; Proctology; Success; Surgery; Z-POEM; Diverticulotomy; Endoscopy; Zenker’s diverticulum; Submucosal tunnel
• ISSN: 0930-2794; 1432-2218
• DOI: 10.1007/s00464-020-07861-5

Background In peroral endoscopic myotomy for Zenker’s diverticulum (Z-POEM), the cricopharyngeus muscle is divided within a submucosal tunnel started in the hypopharynx. We aimed to evaluate the safety and preliminary outcomes in patients who underwent a modified version of the Z-POEM where the tunnel is made directly overlying the cricopharyngeus, the m ucosal i ncision and m uscular i nterruption (MIMI) approach, and to compare these with patients who underwent a non-tunneled flexible endoscopic approach. Methods All patients with ZD who were treated by flexible endoscopy at our institution between January 2015 and February 2020 were identified by a retrospective chart review. Dysphagia symptoms were assessed using a validated scoring system. Results Nineteen patients with ZD underwent MIMI (mean age 76.1 years, 68.1% male) and seven patients underwent non-tunneled flexible endoscopic approach (mean age 64.4 years, 85.7% male) during the study period. Mean ZD size was 2.8 cm in the MIMI group and 1.9 cm in the non-tunneled group ( p  = 0.03). Clinical success was achieved in 17/19(89.5%) MIMI patients and 7/7(100%) of non-tunneled flexible endoscopic patients ( p  = 0.101). Dysphagia scores improved in both groups, although this difference was only significant in the MIMI group ( p  ≤ 0.001). Recurrence occurred in 2/17(11.7%) MIMI patients and 3/7(42.9%) non-tunneled flexible endoscopic patients ( p  = 0.096). There were 4 complications, including one pharyngeal perforation requiring open surgical repair in a patient with a small ZD with an associated cricopharyngeal bar in the MIMI group. Median length of follow-up was 290 [142; 465] days in the MIMI group and 1056 [258; 1206] days in the non-tunneled group ( p  = 0.094). Conclusions MIMI is a technically feasible and effective treatment for ZD. Care should be taken in patients with a cricopharyngeal bar and small ZD, as this may increase the risk of perforation. Larger studies with long-term follow-up are needed to determine if MIMI reduces the risk of symptom recurrence when compared to non-tunneled flexible endoscopic approaches.