RESUMO
Background: Peroral endoscopic myotomy (Z-POEM) is an effective treatment for Zenker's diverticulum (ZD), but procedural time and safety vary based on technique. Modified Z-POEM approaches incorporating fewer submucosal tunnels may offer advantages. Methods: In this retrospective, single-center study, we compared outcomes among 20 patients with ZD undergoing standard Z-POEM (2 tunnels), single-tunnel Z-POEM (ST Z-POEM), or tunnel-free Z-POEM (TF Z-POEM). All procedures included mucosotomy over the septum and deep extension of myotomy into the esophagus (2 cm). Primary endpoints were procedural time, clinical success, and adverse events. Results: Patients had a mean age of 67.3±12.2 years, and 70% presented with respiratory symptoms. Mean procedure times were 45 min (standard Z-POEM), 33 min (ST Z-POEM), and 30 min (TF Z-POEM), with a statistically significant difference between the standard and TF Z-POEM groups (P=0.014). Technical success was 100%, and the mean hospital stay was 1.3±1.3 days. One adverse event (5%) occurred. Clinical success, defined as improvement in dysphagia score (3 to 0.05, P<0.001) and resolution of respiratory symptoms, was achieved in all patients. Conclusions: In this study, modified Z-POEM techniques utilizing single-tunnel or tunnel-free approaches, combined with over-the-septum mucosotomy and deep esophageal myotomy (2 cm), demonstrated feasibility, safety and a significantly shorter procedural time compared to standard Z-POEM. These findings suggest potential benefits for ZD treatment, warranting further investigation in larger prospective studies.
RESUMO
BACKGROUND: Studies of learning experience in endoscopic submucosal dissection (ESD) commonly originate from the East. Little is known about the performance of ESD in low-volume western centers. Furthermore, it is unclear whether ESD can be self-taught without a tutored approach. METHODS: We performed a retrospective analysis of consecutive ESDs, performed in an untutored prevalence-based fashion by a single operator at a private Greek hospital from 2016-2020. Out of 60 lesions, standard ESD was applied for 54 and enucleation for 6; 41 were mucosal and 19 submucosal; 3 esophageal, 24 gastric, one duodenal, 12 colonic, and 20 rectal. RESULTS: Pathology revealed carcinoma (n=14), neuroendocrine tumor (n=7), precancerous lesion (n=27), or other submucosal tumors (n=12). The rates of en bloc and R0 resection were 98% and 91%, respectively. The median resection speed was <3 cm2/h for the first 20 cases, but improved progressively to ≥9 cm2/h after 40 cases. Two patients underwent laparoscopic surgery for colonic perforation, and one received a blood transfusion because of delayed bleeding (serious adverse event rate: 5%). No deaths occurred. The median hospital stay was 1.3 days. Variables associated with improvement in ESD speed during the second period of the study were the application of countertraction and the experience acquired through other endosurgical techniques. CONCLUSIONS: ESD was safe and effective in a low-volume center, with an acceptable adverse events rate. At least 40 mixed cases were needed to achieve a high resection speed. Additive experience gained through other endosurgical procedures probably contributed to the improvement in performance.