Daniela Fluxa, MD1, Pedro Palacios, MD1, Mihir S. Wagh, MD, FACG2 1Mayo Clinic, Jacksonville, FL; 2Mayo Clinic Florida, Jacksonville, FL
Introduction: Zenker-like traction diverticulum is a rare complication after anterior cervical discectomy and fusion (ACDF) and often leads to symptoms such as dysphagia, regurgitation, aspiration and/or weight loss. Is thought to be caused by trauma to the esophagus from the self-retaining retractor and continuous friction between the screw plates and pharynx leading to scar tissue, esophageal wall weakness and diverticulum formation. Treatment modalities have typically included rigid endoscopic therapy and open surgery. However, a fixed diverticular pouch and poor cervical mobility makes a rigid endoscopic approach difficult. We present two patients who underwent successful flexible endoscopic therapy via per oral endoscopic myotomy (Z-POEM) with excellent symptom relief.
Case Description/Methods: Patient 1: 56-year-old female with history of ACDF (C5/C6) 18 years ago, reported dysphagia, regurgitation and postprandial cough starting shortly after surgery. On evaluation, esophagram showed a Zenker-like diverticulum. Upper endoscopy (EGD) showed an oozing mass in the diverticulum and erosion of the cervical hardware within the pouch (Figure 1A). PET CT showed thickening of the upper esophagus adjacent to the cervical hardware with positive FDG uptake. Repeat EGD with biopsies was obtained with pathology showing granulation tissue. Decision was made to proceed with endoscopic cricopharyngeus myotomy by using the Z-POEM technique (Figure 1B). Meticulous submucosal dissection and myotomy was performed avoiding the region of hardware protrusion and fibrosis. No esophageal leak was seen on esophagram the next day. At follow-up, she reported significant improvement of symptoms with Dakkak and Bennett dysphagia score of 0 (no dysphagia) compared to 3 (dysphagia to solids and liquids) prior to the Z-POEM.
Patient 2: 62-year-old female with history of ACDF (C4-C7, 3 years ago) presented with dysphagia 4-5 months after surgery. Evaluation with esophagram and EGD confirmed the diverticulum with a protruding mass from hardware erosion into the diverticulum (Figure 1C). Endoscopic cricopharyngeus myotomy with a Z-POEM technique was performed (Figure 1D) and esophagram was negative for leak the following day. At 12 weeks follow up, the patient reported significant improvement of symptoms with dysphagia score of 1 (dysphagia to solids) compared to 3 prior to Z-POEM.
Discussion: Z-POEM is a safe and effective minimally invasive flexible endoscopic option for treatment of Zenker-like traction diverticulum after ACDF.
Figure: Figure 1. Upper endoscopy and Z-POEM images. A. Upper endoscopy showing protruding mass with oozing in addition to erosion of the cervical hardware within the diverticulum. B. Cricopharyngeus per oral endoscopic myotomy with Z-POEM technique. C. Upper endoscopy showing nodular mucosa within the diverticulum, from granulation tissue related to cervical hardware. D. Cricopharyngeus per oral endoscopic myotomy with Z-POEM technique.
Disclosures:
Daniela Fluxa indicated no relevant financial relationships.
Pedro Palacios indicated no relevant financial relationships.
Mihir Wagh: Boston Scientific – Consultant. Creo Medical – Consultant. Fujifilm – Consultant. Micro Tech – Consultant. Olympus – Consultant.
Daniela Fluxa, MD1, Pedro Palacios, MD1, Mihir S. Wagh, MD, FACG2. P4553 - Per-Oral Endoscopic Myotomy For Treatment Of Zenker-Like Traction Diverticulum Secondary To Cervical Hardware Erosion, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.
