Introduction

Nowadays, endoscopic treatment for esophageal Zenker's diverticulum is considered the standard of care, with flexible endoscopic septotomy (FES) being the first technique to be widely adopted. Since 2016, submucosal tunneling Per-Oral Endoscopic Myotomy (Z-POEM) has emerged as an innovative therapeutic approach. However, medium-term efficacy comparisons between Z-POEM and FESremain limited.

Aims & Methods

The aim of this study was to compare the clinical success and safety of Z-POEM and FES.
This study was a retrospective analysis of a large group of patients treated for Zenker's diverticulum across two tertiary care centers. The patients were divided into two groups: those who underwent Z-POEM between 2021 and 2024, and those who underwent FES between 2008 and 2024. Demographic and clinical data, including Charlson Comorbidity Index, Kothari scores, clinical success rates, adverse events, and follow-up duration, were analyzed and compared among the two groups.

Results

Treatment in the study period. Of these, 32 patients (mean age 66.8 ± 10.7 years) underwent Z-POEM, while 34 patients (mean age 73.5 ± 10.2 years) underwent FES. The mean Charlson Comorbidity Index was similar between groups (Z-POEM: 3.28 ± 1.80 vs. FES: 3.4 ± 1.6; p = 0.708). The pre-procedural Kothari-Haber score was comparable (mean 7.3 ± 1.4 for Z-POEM vs. 7.3 ± 1.1 for FES; p= 0.981). The post-procedural Kothari-Haber score was significantly lower in the ZPOEM group (1.3 ± 1.3) compared to the FES group (2.7 ± 2.8; p = 0.010), indicating better symptom resolution. The median follow-up period was 37.7 months (IQR: 14.8 – 74.6 months) for the FES group and 12.2 months (IQR: 7.4 – 21.9 months) for the Z-POEM group (p < 0.0001). Technical success was achieved in 100% in both groups. Clinical success was significantly higher in the Z-POEM group (93.8%; 95% CI: 75% - 99%) compared to the FES group (64.5%; 95% CI: 50% - 82%; p= 0.005). The rate of adverse events was lower in the Z-POEM group (6.25%) compared to the FES group (23.53%), however this difference did not reach statistical significance (p= 0.084).

Conclusion

This multicenter retrospective study suggests that Z-POEM is an effective and safe alternative to FES for the treatment of Zenker’s diverticulum. The Z-POEM technique demonstrated a significantly higher clinical success rate and a trend towards fewer adverse events. Of particular interest, no differences in terms of efficacy and adverse events were observed between the first 10 patients (during the learning curve) treated with Z-POEM and those treated thereafter. It should be noted that although the follow-up period for Z-POEM was generally shorter, no recurrence of symptoms was observed even in patients with longer follow-up durations. These findings support the use of Z-POEM as a viable and effective approach, warranting further investigation in larger multicenter cohorts to confirm its advantages.

References

Bizzotto A, Iacopini F, Landi R, Costamagna G. Zenker's diverticulum: exploring
treatment options. Acta Otorhinolaryngol Ital. 2013 Aug;33(4):219-29. PMID:
24043908; PMCID: PMC3773964.
Elkholy S, El-Sherbiny M, Delano-Alonso R, et al . Peroral endoscopic myotomy as treatment for Zenker's diverticulum (ZPOEM):
a multi-center international study. Esophagus. 2021 Jul;18(3):693-699. doi:
10.1007/s10388-020-00809-7. Epub 2021 Jan 2. PMID: 33387150.
Kahaleh M, Mahpour NY, Tyberg A, et al. Per Oral Endoscopic Myotomy for Zenker's
Diverticulum: A Novel and Superior Technique Compared W ith Septotomy? J Clin
Gastroenterol. 2022 Mar 1;56(3):224-227. doi: 10.1097/MCG.0000000000001579.
PMID: 34183618.
Steinw ay S, Zhang L, Amundson J, Nieto J, Desai P, Jacques J, Bejjani M, Pioche M,
Kumta N, Hernandez-Mondragon O, Ujiki M, Khashab M. Long-term outcomes of
Zenker's peroral endoscopic myotomy (Z-POEM) for treatment of Zenker's
diverticulum. Endosc Int Open. 2023 Jun 29;11(6):E607-E612. doi: 10.1055/a-2067-
9105. PMID: 37397859; PMCID: PMC10310448.
Sw ei, E., Pokala, S.K., Menard-Katcher, P. et al. Comparison of Zenker’s per-oral
endoscopic myotomy (Z-POEM) w ith standard flexible endoscopic septotomy for
Zenker’s diverticulum: a prospective study w ith 2-year follow -up. Surg Endosc 37,
6818–6823 (2023). https://doi.org/10.1007/s00464-023-10136-4

Disclosure

Giuseppe Grande is consultant for Olympus, Boston Scientific, ERBE, Fujifilm