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IntroductionZenker’s diverticulum (ZD) is a false pulsion diverticulum of the cervical esophagus. It is typically found in older adults and manifests with dysphagia. The purpose of this study is to describe our experience with Per-oral endoscopic myotomy for Zenker’s (Z-POEM) and intraoperative impedance planimetry (FLIP).MethodsWe performed a single institution retrospective review of patients undergoing Z-POEM in a prospective database between 2014 and 2022. Upper esophageal sphincter (UES) distensibility index (DI, mm2/mmHg) was measured by FLIP before and after myotomy. The primary outcome was clinical success. Secondary outcomes included technical failure, adverse events, and quality of life as assessed by the gastroesophageal health-related quality of life (GERD-HRQL), reflux severity index (RSI), and dysphagia score. A statistical analysis of DI was done with the paired t-test (p < 0.05).ResultsFifty-four patients underwent Z-POEM, with FLIP measurements available in 30 cases. We achieved technical success and clinical success in 54/54 (100%) patients and 46/54 patients (85%), respectively. Three patients (6%) experienced contained leaks. Three patients were readmitted: one for aforementioned contained leak, one for dysphagia, and one post-operative pneumonia. Three patients with residual dysphagia underwent additional endoscopic procedures, all of whom had diverticula > 4 cm. Following myotomy, mean DI increased by 2.0 ± 1.7 mm2/mmHg (p < 0.001). In those with good clinical success, change in DI averaged + 1.6 ± 1.1 mm2/mmHg. Significant improvement was found in RSI and GERD-HRQL scores, but not dysphagia score.ConclusionZ-POEM is a safe and feasible for treatment of ZD. We saw zero cases of intraoperative abandonment. We propose that large diverticula (> 4 cm) are a risk factor for poor outcomes and may require additional endoscopic procedures. An improvement in DI is expected after myotomy, however, the ideal range is still not known.

BackgroundZenker’s peroral endoscopic myotomy (Z-POEM) has revolutionized the therapeutic strategy for Zenker’s diverticulum (ZD) with promising results. We conducted this meta-analysis to estimate the safety and efficacy of Z-POEM for ZD and compare the feasibility and effectiveness of Z-POEM with that of flexible endoscopic septotomy (FES).MethodsA comprehensive literature search was conducted in PubMed, EMBASE, Web of Science, and Cochrane Library databases to query for studies that assessed the safety and efficacy of Z-POEM for ZD. All articles published from inception to July 31, 2021 were included. The primary outcomes were the overall technical success rate, clinical success rate, incidence of adverse events, and clinical recurrence rate.ResultsEleven studies involving 357 patients undergone Z-POEM were included. Overall, the quality of included studies was above average, with five studies rated as high quality and six ranked as moderate quality. The overall pooled technical success rate for Z-POEM was 96.3% (95% confidence interval [CI] 93.6–97.9%; I2 = 0%). The total pooled clinical success rate for Z-POEM was 93.0% (95% CI 89.4–95.4%; I2 = 0%). The pooled incidence of adverse events for Z-POEM was 12.4% (95% CI 9.1–16.7%; I2 = 0%). The pooled clinical recurrence rate for Z-POEM was 11.2% (95% CI 7.6–16.2%; I2 = 0%). The clinical success for Z-POEM was significantly better than that of FES (relative risk [RR]: 1.11; CI 95% 1.03–1.18; p = 0.004, I2 = 0%), while there were no significant differences in technical success, adverse events, and clinical recurrence between Z-POEM and FES.ConclusionZ-POEM could be an effective and safe therapeutic modality for ZD, and even has a slightly higher clinical success rate than FES. However, comparative studies with long-term follow-up will be needed to further confirm our finding.

Zenker's diverticulum (ZD) was historically treated with an open transcervical myotomy with diverticulectomy, but endoscopic approaches have gained popularity, though with little recent data. This study aimed to report flexible endoscopic cricopharyngomyotomy (FEC) outcomes, particularly in smaller diverticula. Patients with ZD treated with FEC at a tertiary center were reviewed. Patients were grouped by diverticulum size: small (sZD)≤1.5 ​cm; medium (mZD) ​> ​1.5 ​cm. Of 30 patients, median age, BMI, sex, and comorbidities were similar between sZD (n ​= ​18) and mZD (n ​= ​12). Overall, 80.0 ​% had the procedure performed with a needle knife. Median number of clips for mucosotomy closure (5.0[5.0,6.0]vs.7.0[5.0,7.0]clips;p ​= ​0.051), operative time (59.5[51.0,75.0]vs.74.5[51.0,93.5]minutes;p ​= ​0.498), length-of-stay (1.0[1.0,1.0]vs.1.0[1.0,1.0]days;p ​= ​0.397), and follow-up (20.8[1.1,33.4]vs.15.6[5.4,50.4]months;p ​= ​0.641) were comparable. There were no postoperative leaks; incomplete myotomy occurred in one sZD, yielding a clinical success rate of 96.7 ​%. FEC has a high success rate for ZD and an advantage in small diverticula, difficult to treat with stapling or open technique. •Postoperative outcomes were comparable between sZD and mZD in similar populations.•FEC has an advantage in small ZD that are difficult to treat with other techniques.•FEC is an acceptable treatment with high clinical success for any sized ZD.

BackgroundThe European Society of Gastroenterology and Endoscopy recommends a primarily flexible endoscopic approach for the treatment of Zenker’s diverticulum. Due to the rarity of the disorder, evidence for its effectiveness and safety comes mainly from small, retrospective, single-center studies.MethodsIn this retrospective, observational, multicenter cohort study, data from six German tertiary referral centers were analyzed. The primary outcome parameters were technical and clinical success; among the secondary outcomes, the rates of adverse events (AE) and re-admission with symptomatic recurrence and mortality were the most relevant.ResultsBetween 2003 and 2024, 384 treatments were performed in 327 patients (61.8% male, mean age 74.70 (± 10.60)). Incision methods/techniques were 250 needle knives, 44 ESD knives, 64 stag beetle knives, 24 staplers, one APC-probe, and one Z-POEM. The Zenker’s diverticulum overtube was used in 65.1%, prophylactic clipping in 30.2%, and antibiotic therapy in 25.3% of treatments. The rates of technical and clinical success were 99.2% and 97.4%, and the rates of AE and re-admission with symptomatic recurrence were 11.2% and 16.7%, respectively. Mortality was 0.3%. Comparative subgroup analyses of 312 diverticula without prior treatment versus 72 symptomatic recurrences and incision methods/techniques showed no significant differences in outcome parameters. The use of additional devices and prophylactic measures (clipping, antibiotic therapy) were not independent predictors of technical/clinical success or AE in uni-/multivariable regression analysis.ConclusionsFlexible endoscopic Zenker’s diverticulotomy is a safe and effective minimally invasive treatment. Recurrences can be treated by flexible endoscopy with comparable results. None of the cutting methods, ancillary devices, or prophylactic measures showed superiority in effectiveness or safety.

IntroductionMinimally invasive endoscopic options are safe and effective alternatives to surgery for the treatment of symptomatic Zenker’s diverticulum (ZD). However, there is no consensus on the gold-standard approach. We compared the safety and efficacy of Zenker’s peroral endoscopic myotomy (Z-POEM), flexible diverticulotomy (FD), and rigid diverticulotomy (RD) for the management of ZD.MethodsPatients undergoing treatment for ZD at three UK tertiary referral centres were identified and analysed between 2013 and 2023. Patient demographics, procedural details, clinical success, and 30-day adverse events (AE) were recorded. The primary outcomes were technical and clinical success defined as a fall in Dakkak and Bennett dysphagia score to ≤ 1 without re-intervention.ResultsThere was no difference in baseline characteristics amongst 126 patients undergoing intervention (50 RD, 31 FD, 45 Z-POEM). Technical success for RD, FD, and Z-POEM was 80%, 100%, and 100%, respectively (p < 0.001). Over a mean follow-up of 11.0 months (95% CI 8.2–13.9), clinical success amongst those treated was 85.3% (RD), 74.1% (FD), and 83.7% (Z-POEM; p = 0.48) with recurrence in 17.2% (RD), 20.0% (FD), and 8.3% (Z-POEM; p = 0.50). AEs were equivalent between groups (p = 0.98). During this time, 11 patients underwent surgical myotomy with low clinical success (36.4%) and high morbidity.ConclusionEndoscopic options for the treatment of ZD show equivalent rates of success, but failed RD often led to open myotomy with worse outcomes. Flexible endoscopic modalities are both safe and highly effective treatments that may be considered first-line in experienced centres and should be offered before surgery.

BackgroundIn recent years, flexible endoscopic therapy of Zenker’s diverticulum seems to become the standard approach. The aim of this study was to assess the safety, efficacy and short-term outcome of flexible endoscopic diverticulotomy of Zenker’s diverticulum with a pulsed Holmium laser (PHL).Patients and methodsAll patients treated with endoscopic laser-diverticulotomy using a PHL between February 2013 and November 2021 at the University Hospital Salzburg were extracted from our prospectively maintained endoscopic database. Demographic data, size of Zenker’s diverticulum, procedure duration, complications, short-term outcome and rate of recurrence were evaluated.ResultsIn the study period, 45 procedures in 36 patients were performed. Mean depth of the Zenker diverticulum was 21 mm (10–60 mm), mean procedure time was 31 min (15–60 min), intraprocedural adverse events occurred in 2 out of 45 patients (5%) which were both managed endoscopically, post-procedural stenosis occurred in 1 patient (2%). In the follow-up examinations (mean follow-up after 6.4 months), 27 out of 36 patients (75%) were symptom-free, 6 patients (17%) reported an improvement of dysphagia. 3 patients (9%) suffered from persistent dysphagia. After initial symptom relief, a recurrent diverticulum occurred in 5 patients. Endoscopic re-intervention with PHL was done in these cases.ConclusionsFlexible endoscopic treatment of primary and recurrent Zenker’s diverticulum using a PHL is a promising, safe and effective treatment with, in our opinion, technical advantages in comparison to the CO2 laser. Further controlled prospective trials are needed.

Multiple therapeutic modalities including surgery and rigid and flexible endoscopy have been adopted to manage Zenker's diverticulum (ZD). Minimally invasive flexible endoscopic septotomy (FES) techniques have been increasingly favored over the past 20 years; however, long-term data are still scanty. The aim of this study is to evaluate early and long-term outcomes of FES for naive ZD in a single-center setting. From 2010 to 2017, ZD patients treated with FES were included in a prospectively maintained database (NCT03948438). Those who had already been treated surgically or endoscopically were excluded from the analysis. The Dakkak and Bennett dysphagia scale was used to rate the dysphagia. Persistent complete or near-complete resolution of symptoms (Dakkak and Bennett 0 or 1) was defined as clinical success. Postprocedural adverse events were reported according to ASGE lexicon. Overall, 256 consecutive patients were treated. Mean pouch size was 29.8 ± 11.3 mm. The procedure was successfully completed in all scheduled patients, with an early clinical success of 96.1%. Adverse events occurred in 3.5% (9/256) of patients. Eight of them were mild/moderate with no fatal events, whereas one patient required surgery. Recurrences occurred in 31.3% (80/256) of treated patients after a mean time of 9 ± 3 months and 95% of recurrences were treated by a second FES. At an average follow-up of 5.5 years, 95.3% of patients were asymptomatic after a mean number of 1.3 procedures. FES is a safe and effective treatment modality for patients with ZD. Recurrence rate is significant; however, endoscopic reintervention is associated with long-term relief of dysphagia.

Most Zenker’s diverticula (ZD) cohort studies are single-institution retrospective observational studies of recurrence rates. There is a gap in the literature regarding patient-reported outcomes after ZD surgery. This study was conducted to compare if open transcervical diverticulectomy (OD) is better than endoscopic laser diverticulectomy (ELD) or endoscopic stapler-assisted diverticulectomy (ESD). The study design is of systematic review and meta-analysis. The following databases were searched: SCOPUS, EMBASE, PubMed, and Word of Science through December 2017. The quality of the studies was evaluated using 22-item STROBE checklist with 3 independent physician reviewers. The Inter-rater reliability was calculated both as a percent and utilizing Cohen’s Kappa. For the meta-analysis, Cohen’s d for an effect size was calculated for all studies comparing dysphagia results before and after surgery. A total of 865 patients were treated across 11 selected publications, of which 106 patients were treated OD, 310 ELD, and 449 with an ESD approach. Patient-reported dysphagia outcomes were reported as Cohen’s d (confidence interval): OD, ELD, and ESD were 1.31 (0.88, 1.74), 1.91 (1.62, 2.20), and 2.45 (2.04, 2.86), respectively. The pooled effect of all studies for dysphagia was 2.22 (1.85, 2.59) and regurgitation 2.20 (1.80, 2.59). We did not prove that OD has superior outcomes compared to ESD and ELD. Any method of surgical intervention yields a large effect (i.e., improvement in dysphagia and regurgitation) comparing patient-reported symptoms before and after surgery. Future research, currently underway, includes a prospective, multi-institutional study comparing standardized outcomes between treatments of ZD including symptom resolution, complications, and recurrences using validated measures to define long-term outcomes.Level of Evidence 3