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近年来，采用软镜环咽肌切开术治疗Zenker憩室的情况越来越普遍，所用到的技术和工具也越来越多。Mittel等人在Endoscopy上发表了一篇研究，分析了Zenker憩室软镜肌切开术的实践模式、各种技术和结局。来自梅奥诊所的Norio Fukami发表了对该研究的评论，除了讨论该研究外，还讨论了其他有前景的治疗方法——Z-POEM和肌切除术，并讨论了这些技术适合于什么样的Zenker憩室。与大家分享这篇评论。 Flexible endoscopic Zenker’s diverticulum treatments – too many in the tool box? 软镜治疗Zenker憩室-可选择的工具太多？ Treatments for Zenker’s diverticulum have evolved over the decades. The surgical approach evolved from open surgery to rigid endoscopic cricopharyngeal bar myotomy, which offered a shorter hospital stay, high efficacy, and less morbidity. Flexible endoscopic cricopharyngeal bar myotomy was reported in 1995 and was initially performed in only a limited number of centers owing to its perceived difficulty and potential complications. Over the years, however, many centers have adopted this method with success. A needle-knife, with or without a diverticuloscope to isolate the cricopharyngeal bar, was used. More recently, endoscopic submucosal dissection knives have often been used. 几十年来，Zenker憩室的治疗方法一直在不断地发展。手术方法从开放手术演变为了硬镜环咽肌切开术，硬镜环咽肌切开术具有住院时间更短、有效性较高和发病率更低等特点。软镜环咽肌切开术于1995年报告，且由于手术难度以及可能引发的并发症，最初只在少数的几个中心进行。但最近几年来，许多中心都进行了软镜环咽肌切开术，并取得了成功。过去使用的是针状刀技术（联合或不联合憩室镜分离环咽嵴），而最近经常使用的则是内镜黏膜下剥离技术。 In 2014, Kedia et al. reported a new method with stepwise exposure of the cricopharyngeal muscle by mucosal incision and submucosal dissection. This method offered the advantage of isolating the structures and visualizing the cricopharyngeal muscle in order to selectively and completely incise down to the bottom of the diverticulum while avoiding perforation, with the aim of improving long-term efficacy. Our group reported further details of the method with slight modification in video format, and named this method “full-exposure cricopharyngeal myotomy.” 2014年，Kedia等人报告了一种新的方法，通过黏膜切开和黏膜下剥离逐步使环咽肌显露出来。这种方法的优点是可以分离结构且可直接看到环咽肌，从而可以选择性地完全切开至憩室底部，同时又能避免穿孔，以改善长期的治疗效果。2017年，我们的研究进一步介绍了这个方法的更多详细特点，且将该方法命名为“全暴露环咽肌切开术”。 In this issue of Endoscopy, Mittel et al. report on a retrospective study of practice patterns in Zenker’s myotomy from 12 centers, with details of tools, techniques, and outcomes. I congratulate the authors on their effort to investigate modern treatment modalities for symptomatic Zenker’s diverticulum in the United States. 在Endoscopy中，Mittel等人报告了一项回顾性研究，对来自12家中心的Zenker肌切开术实践模式进行了分析，并详细介绍了多种工具、技术和结局。作者对Mittel等人在研究美国症状性Zenker憩室的现代治疗方式方面的工作表示赞赏。 Not surprisingly, a variety of tools have been used over the years. Two major methods were used: traditional septotomy and submucosal dissection on the septum followed by myotomy (exposure technique). The mean Zenker’s diverticulum size was 2.7 cm (range 0.5–7 cm). The authors used the Eckardt score to assess dysphagia symptoms, with clinical success defined as an overall score of < 3 and dysphagia score of < 2. Overall technical success was 98.1 % and clinical success was 78.1 %. 研究发现，多年来，有各种各样的工具应用于Zenker憩室的治疗。主要使用的方法有两种：一种是常规中隔切开术，另一种是先进行隔膜的黏膜下剥离术，然后再进行肌切开术（暴露技术）。Zenker憩室平均尺寸为2.7 cm（范围0.5-7 cm）。该研究使用Eckardt评分评估吞咽困难症状，将总分< 3、吞咽困难评分< 2定义为临床成功。总体技术成功率为98.1%，临床成功率为78.1%。 The traditional method had lower clinical success (75.2 %) than the exposure technique (90.9 %), though not statistically different, which is probably due to the lower number of cases with the exposure technique (22 vs. 101). The clinical success rate was significantly higher with a hook knife than a needle- or insulated tip knife. There were no significant differences in outcomes between centers with different case volumes (cases up to 10, 11–20, > 20). 与暴露技术的临床成功率（90.9%）相比，常规方法的临床成功率（75.2%）要更低，但差异不显著，这可能是因为采用暴露技术的病例数量较少（22 vs. 101）。hook刀的临床成功率要显著高于针状刀或顶端带有绝缘陶瓷圆球的电刀（IT刀，insulated-tip knife）。病例数量（≤10、11-20、> 20）不同的中心之间的结局无显著差异。 The adverse event rate was 8.1 %, with a higher perforation rate for the exposure technique (12.5 %) than the traditional technique (2.9 %). This is remarkable because the exposure technique aims to reduce the risk of inadvertent perforation by visualizing each layer of the wall. Familiarity with anatomical structures comes with experience, as gastroenterologists are not usually familiar with structures in this region. It is possible that perforation occurred in the early phase of technical adaptation. Repeat intervention was required for symptoms in 15.5 % of patients, which is comparable to the rate reported in previous studies; however, short-term follow-up (mean 5.7 months) of only 76.4 % of the original patient cohort may have lowered the reintervention rate. 不良事件发生率为8.1%，其中暴露技术的穿孔率（12.5%）高于常规技术（2.9%）。这一点特别值得注意，因为暴露技术的目的就是希望通过可视化腔壁的每一层分层结构来降低意外穿孔的风险。熟悉解剖结构需要经验的积累，因为胃肠病学家并不是都熟悉该区域的结构。穿孔有可能发生在技术调整的早期阶段。15.5%的患者因出现症状需要进行再次干预，这与先前研究报告的发生率相当；然而，在最初的患者队列中实现了76.4%患者的短期随访（平均5.7个月），这可能降低了再干预率。 Multiple and linked confounding variables make analysis difficult in this study, such as differences between knives, techniques, and the participating medical centers. Importantly, we do not have data from individual centers with regard to case volume, techniques, tools, and success rates. Variables include tools (insulated tip knife may be inferior to other knives), technique (exposure technique may offer higher clinical success), and learning curve. The hook knife was used more frequently in the exposure technique (54.2 %) than in the traditional technique (21.9 %); the insulated tip knife was used only for the traditional technique. 多个和相关的混杂变量使得该研究的分析难以进行，例如不同的手术刀、不同的技术以及参与的医疗中心之间的差异。重要的是，没有单个中心关于病例量、技术、工具和成功率的数据。变量包括手术工具（IT刀可能不如其他手术刀）、技术（暴露技术可能具有更高的临床成功率）和学习曲线。hook刀在暴露技术中的使用频率（54.2%）要高于在常规技术中的使用频率（21.9%）；IT刀仅在常规技术中使用。 Flexible endoscopic treatment of Zenker’s diverticulum has evolved over recent years. Centers with lower case volumes may have adopted the newer (exposure) technique and tools, as they may have embarked on treatment for Zenker’s diverticulum more recently, when more knowledge and technical details had become available. The traditional technique using a needle-knife and insulated tip knife is likely to have been used at the high-volume centers in the early years. Thus, treatment outcomes of centers are not solely a reflection of the learning curve. 近年来，Zenker憩室的软镜治疗一直在不断发展。病例数量较少的中心可能会采用较新的技术（暴露技术）和工具，因为他们可能最近才开始治疗Zenker憩室，而此时已经可以了解到更多的知识和技术详情。而使用针状刀和IT刀的常规技术很可能早期是在病例数量较多的中心进行。因此，多个中心的治疗结局反映的不仅仅是学习曲线。 The authors have acknowledged these issues in the study limitations and subgroup analysis was not possible. Nevertheless, it is notable that centers with case volumes of 10 or less showed excellent outcomes. Despite the limitations of this study, it is safe to conclude that Zenker’s diverticulotomy is feasible and adaptable at such tertiary referral centers. Mittel等人承认，这些问题都是研究的局限性，而且不可能进行亚组分析。然而，值得注意的是，病例数量≤10的中心显示出极好的结局。尽管该研究存在局限性，但可以肯定的是，三级转诊中心可以进行Zenker憩室切开术，且可以对该操作进行调整。 We need to standardize the flexible endoscopic technique for treatment of Zenker’s diverticulum and aim for higher clinical success rates and, more importantly, lower recurrence rates, as flexible endoscopy offers better maneuverability and visualization. The recurrence rate of 10 %–15 % was similar to that for rigid endoscopic treatment. Costamagna et al. reported the prognostic variables for clinical success with flexible endoscopic septotomy. Pretreatment diverticulum size > 50 mm, septotomy length < 25 mm, and residual diverticulum of 10 mm were prognostic indicators for recurrence. Complete cricopharyngeal bar myotomy with minimum residual cricopharyngeal bar or diverticulum reduces the risk for residual symptom or recurrence. 由于软镜具有较好的可操作性和可视性，我们需要为Zenker憩室治疗的软镜技术制定统一的标准，并追求更高的临床成功率，更重要的是，要达到更低的复发率。软镜技术的复发率为10%-15%，与硬镜治疗的复发率相当。Costamagna等人报告了软镜下中隔切开术临床成功的预后因素。治疗前憩室尺寸〉50 mm、中隔切开长度〈25 mm、10 mm的残余憩室是复发的预后指标。完全环咽肌切开术以及尽量减少环咽嵴或憩室的残留长度可降低出现残留症状或复发的风险。 Other promising treatment options reported recently are peroral endoscopic myotomy for Zenker’s diverticulum (Z-POEM) and myectomy. Z-POEM creates a submucosal tunnel in order to expose and completely cut the cricopharyngeal bar, keeping the overlying mucosa intact. However, perforation has still been reported (5 %), requiring hospital admission. Moreover, the intact mucosa that was covering the cricopharyngeal bar would become the mucosal flap and it is not clear how this mucosal flap affected patients after myotomy. Z-POEM carries a risk of possible leakage at the entry site, which could lead to abscess formation as it creates a pocket within the submucosa to adventitia or fascia. The procedure requires complete entry site closure to prevent complications, and multiple clips may involve significant discomfort, cost, and time. 最近报告的其他有前景的治疗方案是治疗Zenker憩室的经口内镜下肌切开术（Z-POEM）和肌切除术。Z-POEM创建了一个黏膜下隧道，以便暴露和完全切割环咽嵴，使得覆盖环咽嵴的黏膜保持完整。然而，仍然还是会出现穿孔（5%），导致需要住院。此外，覆盖环咽嵴的完整黏膜会变成黏膜瓣，目前尚不清楚肌切开术后该黏膜瓣会如何影响患者。Z-POEM具有隧道入口可能会有渗漏的风险，这可能会导致脓肿，因为Z-POEM在黏膜下层到外膜或筋膜内创建了一个囊袋。该手术需要完全闭合隧道入口以防止并发症的发生，且多个钛夹可能会带来严重的不适，并导致成本和时间的大大增加。 Myectomy is an attractive option to reduce recurrence. Creating a wide window by removing a large area of the cricopharyngeal bar may provide long-lasting resolution of symptoms. No recurrence of symptoms was reported (0 %), although the myotomy group had a higher recurrence rate (22.7 %) than commonly reported. Larger studies would be required to confirm superiority of myectomy in reducing recurrence. 肌切除术是降低复发率的一种非常有吸引力的选择。通过切除大面积的环咽嵴来创建一个较大的空间，可能可以长期消除症状。没有出现症状复发（0%），但是肌切开术组的复发率（22.7%）要高于通常报告的复发率。需要更大规模的研究来证实肌切除术在降低复发率方面的优越性。 The best technique may differ among patients with different symptoms, diverticulum sizes, and comorbidities. Z-POEM has the advantage of performing complete and extended myotomy to the esophageal lumen, which may be most suitable for a smaller diverticulum with significant symptoms associated with cricopharyngeal hypertrophy. Myectomy has the advantage of removing the septum of large diverticula, for which simple cricopharyngeal bar myotomy risks higher recurrence. Conventional septotomy, or rather exposure technique, would be the standard treatment for a medium Zenker’s diverticulum (arguably 2–5 cm). Classification of clinically relevant Zenker’s diverticulum to aid selection of a treatment modality is eagerly awaited. 对于具有不同症状、不同憩室大小和不同合并症的患者，最佳的治疗方式可能会有所不同。Z-POEM的优点是可以对食管腔进行完全和延长的肌切开术，可能最适合于伴有环咽肌肥厚相关明显症状的较小憩室。肌切除术的优点在于切除了大憩室的隔膜，因为对于大憩室而言，单纯的环咽肌切开术术后复发的风险较高。常规的中隔切开术，或者更确切地说是暴露技术，将是中等大小Zenker憩室（理论上为2-5 cm）的标准治疗。迫切需要对临床有意义的Zenker憩室进行分类，从而为患者选择合适的治疗方式提供帮助。 Reference: Fukami N. Flexible endoscopic Zenker's diverticulum treatments - too many in the tool box? Endoscopy. 2021 Apr;53(4):354-356. doi: 10.1055/a-1373-5490. Epub 2021 Mar 29. PMID: 33780976. 声明： 本文翻译为来自柳叶新潮团队编辑整理，仅供学习交流。 |
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