Open Zenker's peroral endoscopic myotomy: technical and clinical outcomes of a novel technique (with videos).

Objective: Zenker's peroral endoscopic myotomy (Z-POEM) has shown excellent technical and clinical success. However, the remnant mucosal flap can result in symptom recurrence. In addition, mucosal closure can be technically challenging. This study introduces Open Z-POEM (OZ-POEM), a modified approach that allows additional mucosotomy by eliminating mucosal closure.

Methods: This retrospective observational study included patients with Zenker's diverticulum who underwent OZ-POEM from December 2022 to May 2024. The primary outcome was clinical success (Kothari-Haber score <3). Secondary outcomes included technical success, recurrence, and adverse events.

Results: A total of 53 patients (mean age 74 ± 10 years; 69.8% male) underwent OZ-POEM in 2 centers (United States and India), with a mean diverticulum size of 26 ± 14 mm. OZ-POEM was technically successful in all patients, with a mean procedure time of 19 ± 6 minutes. There was a significant decrease in the median (IQR) Kothari-Haber score from 7 (5-8) to 1 (0-1) (P < .01) after a median follow-up of 23.5 weeks. One patient (1.9%) had a post-procedural moderate adverse event, a late ulcer resolved with medical therapy, and another (1.9%) had a severe adverse event, an early leak treated with vacuum therapy; both were asymptomatic at follow-up. Two patients (3.8%) experienced symptomatic recurrence after a median of 28.5 weeks, requiring reintervention.

Conclusions: OZ-POEM is a novel, feasible, and safe procedure with a short procedure time, eliminating the need for incision site closure. The incorporation of extensive mucosotomy is the likely reason behind the very low recurrence rate (3.8%); however, prospective comparative studies are necessary to support these findings.