Comparison of flexible endoscopic needle-knife septotomy and peroral endoscopic myotomy for treatment of Zenker's diverticulum

Abstract

Treatment of Zenker's diverticulum (ZD) has evolved from flexible endoscopic septotomy (FES) to peroral endoscopic myotomy for ZD (Z-POEM). In this study, we compare the efficacy and safety of flexible endoscopic needle-knife septotomy (FENKS) and Z-POEM for symptomatic ZD. Consecutive patients at a single institution who underwent endoscopic ZD treatment by FENKS or Z-POEM were identified. Demographics, clinical characteristics, procedure technique, technical and clinical success, and adverse events (AEs) within 30 days were reviewed and compared between the 2 groups. AEs were classified by the AGREE classification. Baseline and postprocedure Dakkak and Bennett (DB) scores were reported at 6, 12, and 24 months. Clinical success (DB score≤1) was assessed by per-protocol (PP) and intention-to-treat analyses (ITT). Sixty patients (55% men; mean age, 72 ± 12 years) underwent FENKS (n= 21) or Z-POEM (n= 39) between 2016 and 2023. Baseline clinical characteristics were similar, and overall technical success was 98.3%. Clinical success by PP and ITT analyses at 6, 12, and 24 months after each intervention were similar between both groups. The FENKS group had a higher prevalence (29% vs 5%, P= .018) and severity (P= .032) of AEs and were more likely to be hospitalized after treatment (71% vs 33%, P= .007). During a median follow-up of 18 months, reintervention was required for 5 cases (10%), 2 (9%) in the FENKS and 3 (7.6%) in the Z-POEM group (P= 1.0) a mean 7.6 ± 4.4 months after initial therapy. Treatment of ZD with Z-POEM appears to be safer than FENKS with similar short and midterm clinical success.