Cuadrado Lavín, Antonio

Fraile López, Miguel

López Arias, María Jesús

Moris, María

Rodríguez, Juan Carlos

Terán, Álvaro

Endoscopy

English

UCrea

Double sticker over knife to assess myotomy and mucosectomylength during Zenker’s peroral endoscopic myotomy for Zenker’sdiverticulumFlexible endoscopic therapies are be-coming increasing popular for the treat-ment of Zenker’s diverticulum. In partic-ular, Zenker’s diverticulum peroral endo-scopic myotomy (zPOEM) allows a selec-tive and precise cut of the cricopharyn-geal muscle under direct visualization,improving its effectiveness and safety[1]. A major concern regarding the lengthcut is the risk of perforation and/or diffi-culties in the incisional closure if the cutis extended beyond the fundus, or therisk of recurrence of dysphagia if the pro-cedure is incomplete and/or there is anexcess of mucosal flap remaining.As previously described for myotomylength in achalasia [2], the “doublesticker over knife” technique permits aprecise measurement of Zenker’s diver-ticulum depth and individualization ofthe exact length of myotomy and com-plementary cut of the mucosal flap re-quired. We used the recently described“noninjection nontunnel technique”(Ni-zPOEM) using a scissor-type knife(Clutch-Cutter DP2618DT; Fujifilm Med-ical, Tokyo, Japan), which does notrequire submucosal injection or tunnel-ing [3].First, the scope is advanced close to thediverticular septum, and a sticker isplaced on the sheath of the knifeexternally, aligned with the opening ofthe working channel (▶Fig. 1 a). Withthe scope held in this position, the knifeis advanced further through the workingchannel until the tip reaches the fundusof the Zenker’s diverticulum. A secondsticker is then placed on the knife sheathexternally, again aligning it with theopening of the working channel (▶Fig.1b). These two reference points allowus to precisely measure the Zenker’s di-verticulum depth (▶Fig. 1 c). Ni-zPOEMcontinues with mucosal incision andselective myotomy. The scope is thenplaced again at the septum and the tipE-Videos▶ Fig. 1 Double sticker over knife technique. a The tip of the knife is placed in contact with the septum. A sticker is placed on the knife sheath,aligned with the opening of the working channel. b Without moving the scope, the knife is advanced through the working channel until the tipof the knife reaches the fundus of the Zenker’s diverticulum. A second sticker is placed over the knife sheath. The distance between the twostickers is the desired myotomy length. c, d Mucosal incision and tunneling myotomy is performed until the second sticker reaches the openingof the working channel.Video 1 Use of the “double stickerover knife” technique to assess myot-omy and mucosectomy length duringZenker’s diverticulum peroral endo-scopic myotomy.Fraile-López Miguel et al. Double sticker over… Endoscopy 2024; 56: E945–E946 | © 2024. The Author(s). E945Article published online: 2024-11-08of the knife is advanced through thetunnel until the tip reaches the muscle.Here, the second sticker should alignwith the working channel as it did initi-ally (▶Fig. 1d).Our experience consists of 20 cases witha mean Zenker’s diverticulum size of26.7 (SD 12.7) mm. Technical successwas achieved in all 20 cases (100%) witha mean procedure time of 32.4 (SD 12.8)minutes. Clinical success at 6 weeks’follow-up was 100% (▶Video 1).Endoscopy_UCTN_Code_TTT_1AO_2APConflict of InterestThe authors declare that they have no con-flict of interest.The authorsMiguel Fraile-López1 , Carmen Ribes1, ÁlvaroTerán1, María Moris1, Juan Carlos Rodríguez1,María Jesús López Arias1, Antonio CuadradoLavín11 Gastroenterology and HepatologyDepartment, Clinical and TranslationalResearch in Digestive Diseases, ValdecillaResearch Institute (IDIVAL), Marqués deValdecilla University Hospital, Santander,SpainCorresponding authorMiguel Fraile-López, MD, PhDGastroenterology and HepatologyDepartment, Clinical and TranslationalResearch in Digestive Diseases, ValdecillaResearch Institute (IDIVAL), Marqués deValdecilla University Hospital, Av. deValdecilla s/n, 39008 Santander, Cantabria,Spainmiguelfrailelopez@gmail.comReferences[1] Steinway S, Zhang L, Amundson J et al. Long-term outcomes of Zenker’s peroral endo-scopic myotomy (Z-POEM) for treatment ofZenker’s diverticulum. Endosc Int Open2023; 11: E607–E612. doi:10.1055/a-2067-9105[2] Uchima H, Colán-Hernández J, Aguilar A etal. A simple method to determine the properlength of the gastric myotomy during per-oral endoscopic myotomy for achalasia.Endoscopy 2022; 54: E85–E87[3] Gorrepati VS, Yang D, Draganov PV. Novelnon-injection non-tunnel technique for per-oral endoscopic myotomy of Zenker’s diver-ticulum. VideoGIE 2023; 8: 181–182.doi:10.1016/j.vgie.2023.01.001BibliographyEndoscopy 2024; 56: E945–E946DOI 10.1055/a-2443-6374ISSN 0013-726X© 2024. The Author(s).This is an open access article published by Thieme under theterms of the Creative Commons Attribution License, permit-ting unrestricted use, distribution, and reproduction so longas the original work is properly cited.(https://creativecommons.org/licenses/by/4.0/)Georg Thieme Verlag KG, Oswald-Hesse-Str. 50,70469 Stuttgart, GermanyENDOSCOPY E-VIDEOShttps://eref.thieme.de/e-videosE-Videos is an open access onlinesection of the journal Endoscopy,reporting on interesting casesand new techniques in gastroenterologicalendoscopy. All papers include a high-qualityvideo and are published with a CreativeCommons CC-BY license. EndoscopyE-Videos qualify for HINARI discounts andwaivers and eligibility is automaticallychecked during the submission process.We grant 100% waivers to articles whosecorresponding authors are based in GroupA countries and 50% waivers to thosewho are based in Group B countries asclassified by Research4Life (see: https://www.research4life.org/access/eligibility/).This section has its own submissionwebsite athttps://mc.manuscriptcentral.com/e-videosE946 Fraile-López Miguel et al. Double sticker over… Endoscopy 2024; 56: E945–E946 | © 2024. The Author(s).E-Videos

Double sticker over knife to assess myotomy and mucosectomy length during Zenker's peroral endoscopic myotomy for Zenker's diverticulum

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Double sticker over knife to assess myotomy and mucosectomy length during Zenker's peroral endoscopic myotomy for Zenker's diverticulum

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