Improving Outcomes of Endoscopic Cricopharyngeal Myotomy in Zenker Diverticulum

Esophagus, diverticulum, Zenker diverticulum
A team of investigators assessed the ability of the intraprocedural functional lumen imaging probe to measure cricopharyngeal distensibility in patients undergoing endoscopy cricopharyngeal myotomy for Zenker diverticulum.

Cricopharyngeal distensibility is reduced in patients with Zenker diverticulum (ZD) and is partially reversible by flexible endoscopic cricopharyngeal myotomy (FECM), and the intraprocedural functional lumen imaging probe (FLIP) was found to optimize FECM outcome. These finding were published in Gastrointestinal Endoscopy.

Although FECM allows minimally invasive treatment of patients with ZD, there is currently no standardization of the technique, and more importantly, retreatment is often required due to inadequate clinical response. A team of researchers, therefore, sought to investigate the safety and feasibility of FLIP as an intraprocedural tool to address some of the technical challenges facing cricopharyngeal myotomy for ZD.

In this pilot study, 11 consecutive patients with ZD undergoing FECM were evaluated, and baseline cricopharyngeal distensibility was compared with 16 nondysphagic control patients undergoing routine diagnostic endoscopy for indications other than dysphagia. All myotomies were performed by a single experienced therapeutic endoscopist. Intraprocedural cricopharyngeal distensibility was measured immediately pre- and postmyotomy. To confirm the safety of intraprocedural FLIP, the cricopharyngeal-distensibility index (CP-DI) was used, which was defined as a ratio of the narrowest cross-sectional area (nCSA) and the corresponding intrabag pressure at 40 mL distension. Same procedure myotomy extension was performed in a subgroup if threshold distensibility changes were not met.

The average age of the 11 patients with ZD was 77.0 years (SD=10.7) and 55% were women; the average age of the 16 studied control patients was 52.9 years (SD=18.9) and 75% were women. The majority of the diverticula were of moderate size. Mean baseline nCSA at 40 mL distension was significantly lower in the ZD group than in controls (169.6 vs 227.5 mm2, P <.001). Similarly, CP-DI at 40-mL distension was significantly lower in the ZD group than in controls (3.8 vs 7.6 mm2/mm Hg, P <.001). At the conclusion of the procedures, both nCSA and CP-DI increased significantly in all patients by an average of 74.2 mm2 (95% CI, 35.1-113.3; P =.002) and 2.2 mm2/mm Hg (95% CI, 0.6-3.8; P =.01), respectively. In a subgroup of 6 patients with no significant change in either mean nCSA or CP-DI after initial myotomy, myotomy extension resulted in significant increases in both mean nCSA and CP-DI of 66.6 mm2 (95% CI, 16.4-116.8; P =.03) and 1.9 mm2/mm Hg (95% CI, 0.4-3.3; P =.015), respectively. No adverse events were reported. Limitations of the study include a single center, small sample size, and follow-up duration.

The researchers conclude that their findings “support the potential role of FLIP in the endoscopists’ armamentarium to optimize the clinical outcome of endoscopic CP myotomy in the treatment of ZD.” 

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Zhang LY, Iung-Chiang Wu P, Szczesniak MM, Cook IJ, Craig PI. Clinical utility of cricopharyngeal distensibility measurements during endoscopic myotomy for Zenker’s diverticulum (published online on June 11, 2020). Gastrointest Endosc. doi: