Clin Endosc.  2025 Mar;58(2):261-268. 10.5946/ce.2024.180.

Flexible endoscopic treatment of Zenker’s diverticulum: a retrospective study in a single center from Turkey

• Kenarli K
• Ödemiş B

• KMID: 2566146
• DOI: http://doi.org/10.5946/ce.2024.180

Abstract

Background/Aims
We aimed to contribute to the literature by sharing the findings of patients treated by cricopharyngeal myotomy with a flexible endoscopic septal division.
Methods
This retrospective study included patients with Zenker’s diverticulum who underwent cricopharyngeal myotomy with a traditional flexible endoscopic septal division at our center. Clinical success was defined as a significant reduction in dysphagia score, and relapse was defined as an increase in dysphagia score occurring at any time over 1 month after the procedure.
Results
Fifteen patients with symptomatic Zenker’s diverticulum were treated with 16 cricopharyngeal myotomies. A dysphagia score of 100% indicated clinical success, but three (20%) of the patients experienced recurrence during follow-up.
Conclusions
While advances in interventional flexible endoscopy have opened doors for novel treatments, cricopharyngeal myotomy based on traditional flexible endoscopic septal division remains a reliable approach for treating Zenker’s diverticulum.

Keyword

Dysphagia; Methods; Myotomy; Zenker’s diverticulum

Figure

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  Fig. 1. Diverticuloscopes with painted distal flaps. (A) Constructed in house. (B) Commercial type.

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  Fig. 2. Endoscopic cricopharyngeal myotomy with a needle-knife sphincterotome. Guiding catheter (arrows) placed before myotomy, shows esophageal lumen. (A) Diverticuloscope placed on diverticular bridge for cutting. (B) Single midline incision of septum in cranio-caudal direction at start of myotomy. (C, D) Endoscopic view of septum cut with needle-knife sphincterotome. (E) Endoscopic view after myotomy completion. (F) Clips positioned at the distal aspect of septotomy at end of procedure.

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  Fig. 3. Catheter marked to measure diverticulum cut depth.

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Reference

1. Ferreira LE, Simmons DT, Baron TH. Zenker's diverticula: pathophysiology, clinical presentation, and flexible endoscopic management. Dis Esophagus. 2008; 21:1–8.

2. Peters JH, Mason R. The physiopathological basis for Zenker's diverticulum. Chirurg. 1999; 70:741–746.

3. Maran AG, Wilson JA, Al Muhanna AH. Pharyngeal diverticula. Clin Otolaryngol Allied Sci. 1986; 11:219–225.

4. Watemberg S, Landau O, Avrahami R. Zenker's diverticulum: reappraisal. Am J Gastroenterol. 1996; 91:1494–1498.

5. Weusten BL, Barret M, Bredenoord AJ, et al. Endoscopic management of gastrointestinal motility disorders - part 2: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2020; 52:600–614.

6. Mosher HP. Webs and pouches of the oesophagus, their diagnosis and treatment. Surg Gynecol Obstet. 1917; 25:175–187.

7. Collard JM, Otte JB, Kestens PJ. Endoscopic stapling technique of esophagodiverticulostomy for Zenker's diverticulum. Ann Thorac Surg. 1993; 56:573–576.

8. Ishioka S, Sakai P, Maluf Filho F, et al. Endoscopic incision of Zenker's diverticula. Endoscopy. 1995; 27:433–437.

9. Mulder CJ, den Hartog G, Robijn RJ, et al. Flexible endoscopic treatment of Zenker's diverticulum: a new approach. Endoscopy. 1995; 27:438–442.

10. Perbtani Y, Suarez A, Wagh MS. Techniques and efficacy of flexible endoscopic therapy of Zenker's diverticulum. World J Gastrointest Endosc. 2015; 7:206–212.

11. Jirapinyo P, Sethi A, Abu Dayyeh BK, et al. Devices and techniques for flexible endoscopic management of Zenker's diverticulum (with videos). Gastrointest Endosc. 2021; 94:3–13.

12. Gorrepati VS, Yang D, Draganov PV. Novel non-injection non-tunnel technique for peroral endoscopic myotomy of Zenker's diverticulum. VideoGIE. 2023; 8:181–182.

13. Fair L, Ward MA. Modern approaches to treating Zenker's diverticulum. Curr Opin Gastroenterol. 2023; 39:333–339.

14. Eckardt VF. Clinical presentations and complications of achalasia. Gastrointest Endosc Clin N Am. 2001; 11:281–292.

15. Yuan Y, Zhao YF, Hu Y, et al. Surgical treatment of Zenker's diverticulum. Dig Surg. 2013; 30:207–218.

16. Albers DV, Kondo A, Bernardo WM, et al. Endoscopic versus surgical approach in the treatment of Zenker's diverticulum: systematic review and meta-analysis. Endosc Int Open. 2016; 4:E678–E686.

17. Jones DG, Aloraini A, Gowing SD, et al. Comparing outcomes of open vs flexible and rigid trans-oral endoscopic techniques for the treatment of Zenker's diverticulum. J Am Coll Surg. 2014; 219(4 Suppl):e67.

18. Ishaq S, Hassan C, Antonello A, et al. Flexible endoscopic treatment for Zenker's diverticulum: a systematic review and meta-analysis. Gastrointest Endosc. 2016; 83:1076–1089.

19. Li LY, Yang YT, Qu CM, et al. Endoscopic needle-knife treatment for symptomatic esophageal Zenker's diverticulum: a meta-analysis and systematic review. J Dig Dis. 2018; 19:204–214.

20. Costamagna G, Iacopini F, Bizzotto A, et al. Prognostic variables for the clinical success of flexible endoscopic septotomy of Zenker's diverticulum. Gastrointest Endosc. 2016; 83:765–773.

21. Pang M, Koop A, Brahmbhatt B, et al. Comparison of flexible endoscopic cricopharyngeal myectomy and myotomy approaches for Zenker diverticulum repair. Gastrointest Endosc. 2019; 89:880–886.

22. Aslan F, Yilmaz O, Sengun B, et al. A new technique in treatment of zenker diverticulum: submucosal tunneling endoscopic septum division (z-poem) versus classic endoscopic septomyotomy techniques. Gastrointest Endosc. 2019; 89:AB629.

23. Zhang H, Huang S, Xia H, et al. The role of peroral endoscopic myotomy for Zenker's diverticulum: a systematic review and meta-analysis. Surg Endosc. 2022; 36:2749–2759.

24. Papaefthymiou A, Benjamin N, Telese A, et al. Performance of endoscopic approaches for Zenker diverticulum management: a systematic review and meta-analysis. Endoscopy. 2024; 56(S 02):eP552.

25. Huberty V, El Bacha S, Blero D, et al. Endoscopic treatment for Zenker's diverticulum: long-term results (with video). Gastrointest Endosc. 2013; 77:701–707.