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This article from the American Society for Gastrointestinal Endoscopy (ASGE) provides a full description of the methodology used to inform the final guidance outlined in the accompanying summary and recommendations article for strategies to manage endoscopically placed gastrostomy tubes. This article was developed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework and specifically addresses the utility of PEG versus interventional radiology–guided gastrostomy (IR-G), the need for withholding antiplatelet and anticoagulant medications, appropriate timing to initiate tube feedings, and appropriate selection of the gastrostomy technique in patients with malignant dysphagia. In patients needing enteral access, the ASGE suggests PEG as the preferred technique for initial gastrostomy over IR-G. The ASGE recommends that tube feeding can be safely started within 4 hours of the gastrostomy without the need for an intentional delay. The ASGE suggests that a PEG can be performed without the need to withhold antiplatelet medications. In patients on anticoagulants who need to undergo PEG placement, the ASGE suggests that the periprocedural management of anticoagulants should be based on a multidisciplinary discussion with the patient regarding the risk of bleeding versus cardiovascular adverse events. In patients with malignant dysphagia, either transoral “Pull” PEG or transcutaneous “Direct” PEG can be performed for initial enteral access.

Background and Aims: Zenker’s diverticulum (ZD) is attributed to a poorly compliant cricopharyngeus muscle, and the mainstay of treatment is a cricopharyngeal myotomy. We present a video series summarizing endoscopic treatment options for ZD and related conditions. Methods: We review the rationale and key technique for various endoscopic treatment modalities for ZD, cricopharyngeal bar, and other esophageal diverticula. Results: Standard flexible endoscopic cricopharyngeal myotomy involves the division of the common wall or septum of the ZD, aiming for complete transection of the cricopharyngeus. However, recurrence rates are high, likely owing to incomplete myotomy. Zenker’s peroral endoscopic myotomy (Z-POEM) uses a proximal submucosal tunnel to provide direct visualization of the cricopharyngeus and septum, allowing confirmation of complete myotomy. We demonstrate an over-the-septum modification to simplify the technique. Submucosal fibrosis, commonly seen in patients with prior treatment, limits submucosal dissection. We present a hybrid technique to overcome this, whereby a traditional septotomy is performed until submucosal tissue is visualized. The intact mucosal flap after Z-POEM in a large ZD may contribute to residual dysphagia. We propose Z-POEM with mucosotomy for large ZD. Finally, we demonstrate modifications for treatment of other esophageal diseases, including cricopharyngeal bar and non-Zenker’s esophageal diverticula. Conclusion: Endoscopic treatment options for ZD and related conditions are rapidly expanding. With careful tailoring to individual patient characteristics, our expanding arsenal of options allows effective and safe treatment of a broad spectrum of patients.