Adjunctive resection of residual mucosal flap during Z-POEM for large Zenker's diverticulum

Postoperative hypopharyngeal fistula is an uncommon yet serious complication of open surgery for Zenker's diverticulum, with an incidence of approximately 1%–4%. It is associated with local infection, malnutrition, deterioration of the patient's general condition, and an increased risk of subsequent esophageal stricture. The most valuable therapeutic approach is based on surgical reintervention with reinforced closure, adequate drainage, antibiotic therapy, and optimization of hemodynamic and nutritional parameters. Other methods may also be used, including digestive diversion or conservative management strategies such as radiologically guided drainage. We report the case of a 54-year-old man with a large symptomatic Zenker diverticulum who underwent open mechanical diverticulectomy. The immediate postoperative course was uneventful, and the patient was discharged on day six; however, four days later he was readmitted with painful cervical swelling and signs of infection. Cervical CT with oral contrast demonstrated an extensive hypopharyngeal fistula. Broad-spectrum antibiotic therapy was initiated, and on the second day of hospitalization the patient underwent surgical re-exploration with primary closure of the defect reinforced by a muscular flap and adequate drainage, followed by enteral nutritional support. The postoperative evolution was favorable, with complete closure of the fistula. During follow-up, an esophageal stenosis developed but was successfully managed by endoscopic dilatation. This case highlights the rarity and the management challenges of hypopharyngeal fistula following Zenker's diverticulectomy. It underscores the importance of early recognition and timely surgical intervention using a reinforced closure technique, which is considered the most reliable approach according to current literature for managing fistulas in the hypopharyngeal region. Coordinated postoperative care with rigorous monitoring remains essential to achieve favorable outcomes, despite the potential for long-term sequelae such as esophageal stricture.

Flexible endoscopy (FE), rigid endoscopy (RE), and open surgery (OS) are established treatments for Zenker's diverticulum (ZD); however, comparative data on their clinical outcomes remain limited and inconsistent. We conducted the first multi-center matched cohort study comparing several procedural outcomes across FE, RE, and OS for ZD repair. The study population was matched for age, gender, ASA score, and diverticulum. size resulting in Outcomes assessed included dysphagia scores, clinical and technical success, adverse events (AEs), procedure length, hospital length of stay (LOS), and need for further interventions. Both overall and pairwise comparisons were conducted. Subgroup analyses were performed to assess for comparative efficacy of FE procedure types, effect of prior intervention on procedure success, and the effect the year the procedure was performed on clinical success. There were 202 eligible patients over the study period. Propensity score matching resulted in 125 patients (FE n=44, RE n=36, OS n=45). FE demonstrated higher clinical success than RE (84.6% vs 55.6%, p=0.032) and similar success to OS (88.9%, p=0.712); OS showed higher success than RE (p=0.014). AE rates were lowest with FE (4.5%) compared to RE (8.3%) and OS (11.1%) though this was not statistically significant [p=0.212]. FE had shorter median LOS (0 days vs. 1 day for RE and 3 days for OS, p<0.001) and median procedure lengths (55 min vs. 58 min for RE and 78 min for OS, p=0.018). In this matched cohort, FE has clinical success comparable to OS and superior to RE for ZD repair, with shorter hospital stays, reduced procedure lengths, and a trend toward fewer adverse events. Our matched, multi-center design provides stronger comparative evidence than prior unmatched studies. These findings support FE as a first-line treatment for ZD repair, though prospective studies could further clarify long-term outcomes.

Abstract Introduction Bleeding from a Zenker's diverticulum is a rare occurrence, and currently no formal guidelines exist for its management. It is a potentially life-threatening condition and an important consideration in the differential diagnosis of haemoptysis or haematemesis. Presentation of case A 63-year-old man presented with haemoptysis and haematemesis while on dual antiplatelet therapy for a recent NSTEMI. After resuscitation he underwent a CT angiogram which demonstrated an active contrast blush and pooling of contrast in a pharyngeal diverticulum. At endoscopy a large Zenker's diverticulum was encountered which contained an ulcerated area with general oozing of blood from multiple points and a single brisk bleeding point. Haemostasis was achieved with two syringes of a topical haemostatic agent. Discussion Less than 15 case reports exist in the literature of this clinical entity, and fewer still have been managed successfully via endoscopic methods. The pathophysiology is unclear however may be related to antiplatelet agents exerting a topical effect after lodging in the diverticulum, causing ulceration, diverticulitis and bleeding. Early diagnosis can be challenging as patients may seem to present with haemoptysis, and delay to prompt diagnosis may further delay management. Conclusions This is the first Australian case report of bleeding from a Zenker's diverticulum who underwent successful endoscopic management. It highlights the diagnostic dilemma presented by this clinical entity and the subsequent impacts on management. Endoscopic haemostasis is an ideal intervention either as a definitive procedure in elderly patients unfit for surgery, or initial management as a bridge to surgery.

A perforated Zenker's diverticulum and a difficult airway: A case report

A case report of Zenker's diverticulum misdiagnosed as thyroid nodule

Zenker per-oral endoscopic myotomy (Z-POEM) is increasingly used for the treatment of Zenker's diverticulum. This study aimed to evaluate the safety and short-term outcomes of the novel non-tunnel non-injection Z-POEM (NiZ-POEM) technique for Zenker's diverticulum. This single-center prospective study included patients with symptomatic Zenker's diverticulum who underwent NiZ-POEM between February 2023 and February 2025. The primary outcomes were technical and clinical success at 6 months. Secondary outcomes included quality-of-life improvement, adverse events rates, symptom recurrence and reintervention rates. A total of 24 patients were included, with a median age of 77.5 years (54-98); 16 patients (66.7%) were male. Four patients (16.7%) had previously undergone treatment with subsequent symptom recurrence. The mean diverticulum size was 25 mm (±11.5) and the median procedure time was 36.5 minutes (22-91). Technical success was achieved in all patients, and clinical success at 6 months was 100% (95% CI 86.2-100%). There was a significant improvement in dysphagia, with Dakkak-Bennett <1 in all cases and a median baseline Kothari-Haber Score System decreasing from 8 (2-11) to 0 (0-4) at 6 months post-procedure (p<0.001). Quality of life improved significantly, with MDADI scores increasing from 53 (26-90) at baseline to 95 (71-100) at 1 month (median 41, IQR 32-49) and 99 (65-100) at 6 months (median 41, IQR 36-48). No adverse events occurred, and no symptom recurrence was observed during follow-up. NiZ-POEM is a safe and effective technique for the treatment of Zenker's diverticulum. Its simplified approach may broaden the applicability of Z-POEM in clinical practice.

Background and study aimsMultiple therapeutic modalities, including surgery and rigid and flexible endoscopy, have been adopted to manage Zenker’s diverticulum (ZD). Relief from symptoms such as dysphagia and regurgitation is the main goal of therapy in symptomatic ZD. This study was the first large cohort that aimed to assess efficacy with time and safety of endoscopic diverticulotomy using the Clutch Cutter.Patients and methodsCricopharyngeal myotomy was performed in 43 patients at Hospital Saint Joseph de Paris, a tertiary referral center. Symptoms were analyzed before and at 3, 6, and 12 months post-intervention using an extensive questionnaire about dysphagia, odynophagia, regurgitation, chronic cough, state of health, and complications. Procedure details such as duration, complications, and technical success were recorded.ResultsMean size of ZD was 25.6 mm. Mean procedure time was 48 minutes. No major complications (e.g., perforation, mediastinitis) occurred, although one patient suffered from a sinus piriform wound. Follow-up was performed at 3, 6, and 12 months. During follow-up consultations, patients rated improvement in their symptoms as a percentage. At 12 months, 97% of patients reported 100% improvement.ConclusionsIn patients with treatment-naïve ZD, the Clutch Cutter technique is safe, fast, and provides durable symptom remission.

Abstract Purpose of review We describe the evolution and current application of third space endoscopic techniques, with a focus on their role in treating Zenker’s diverticulum (ZD). We discusses the rationale for moving from traditional surgical approaches to minimally invasive flexible endoscopic options. Recent findings Third space endoscopy, initially developed for dysplastic tissue resection, has expanded to also include treatments for motility disorders. Subsequent innovations with third space techniques (tunnelling within the submucosal space), have revolutionized minimally invasive treatment. Flexible diverticulotomy and Zenker-per-oral endoscopy myotomy (Z-POEM), first described in 2016, has emerged as a safe and effective treatment for ZD, with comparable or superior outcomes to surgical and rigid endoscopic techniques. Numerous technical modifications have been used to further simplify and optimize outcomes. We recommend and personally perform cases collaboratively between otolaryngologists, upper gastrointestinal surgeons and gastroenterologists, particularly on the initial learning curve, for optimal patient outcomes. Summary Third space techniques, particularly flexible diverticulectomy and Z-POEM, represent a major shift in the minimally invasive management of Zenker’s diverticulum. While flexible endoscopy is increasingly used and recommended as first-line treatment, the optimal approach should be tailored to individual patient anatomy, proceduralist expertise, and available resources. Continued innovation, multidisciplinary collaboration, and structured training pathways are essential for advancing practice and improving outcomes in this evolving field.

Treatment of Zenker's diverticulum (ZD) has been revolutionized with the introduction of endoscopic techniques. Z-POEM has been shown to have excellent safety and efficacy. We report our experience with the Z-POEM for the treatment of ZD. This is a single-institution retrospective study from 2020 to 2024. The primary outcome was clinical success, defined as improvement in dysphagia score to ≤ 1 without need for a reintervention the first 6months. Secondary outcomes included technical success, rate of reintervention, and post-procedural complications. A total of 32 patients (male 62.5%, mean age 74.2 ± 10.7years) underwent Z-POEM for treatment of Zenker's diverticulum. The mean diverticulum size was 26.7 ± 9.9mm. The American Society of Anesthesiologists (ASA) grade was 3 in 56.3% of patients; the rest of the patients were ASA grade 2. Technical success was achieved in 100% of patients (n = 32) and clinical success was achieved in 96.9% of patients (n = 31). The mean procedure time was 48.6 ± 19.1min. More than two thirds of the patients (68.8%) were discharged home the same day. One patient developed atrial fibrillation postprocedurally. Mean dysphagia scores improved from 1.5 ± 0.8 before the procedure to 0.09 ± 0.3 after the procedure at most recent follow-up (p < 0.001). Mean regurgitation scores improved from 2.3 ± 1.2 before the procedure to 0.13 ± 0.3 after the procedure at most recent follow-up (p < 0.001). Reintervention due to recurrence of symptoms was required in six patients (18.8%) during a mean length of follow-up of 10.8months (range 1 to 43months). Most of the reinterventions (80%) were required after 17months from the initial Z-POEM. Z-POEM is a safe, effective, and durable treatment for Zenker's diverticulum, but reoperation is needed in 1 out of 5 patients in the short term.

Zenker's diverticulum: endoscopic and surgical treatment outcomes

Submucosal tunneling endoscopic septum division (STESD) is an endoscopic minimally invasive technique for treating esophageal diverticulum. The aim of this study was to evaluate the safety and efficacy of STESD for esophageal diverticulum. This retrospective study enrolled patients with esophageal diverticulum who underwent STESD. In addition to demographic and clinical information, we regularly followed up with the patients to evaluate recurrence. Costamagna and Eckardt scores were used to evaluate changes in symptoms. This study included a total of 62 patients, comprising Zenker's diverticulum (n = 23), mid-esophageal diverticulum (n = 13), and epiphrenic diverticulum (n = 26). The mean size of esophageal diverticulum was 24.3 ± 23.6 mm. The mean procedure time was 36.2 ± 17.9 min, and the mean hospital stay was 4.0 ± 2.8 days. Mucosal injury occurred in one patient, and perforation occurred in one patient. Besides, one patient developed symptom recurrence at 3 months after STESD. Both Costamagna score and Eckardt score significantly decreased postprocedure (p < 0.0001). STESD may be a safe and valid endoscopic minimally invasive procedure for esophageal diverticulum.

ABSTRACTObjectiveTo analyze Medicare reimbursement and utilization trends of Zenker's diverticulectomy from 2000 to 2024.Study DesignRetrospective cross‐sectional study.SettingCenters for Medicare and Medicaid Services (CMS) Physician Fee Schedule (2000–2024) and Part B Medicare Fee‐For‐Service National Summary Data (2000–2022).MethodsUtilization and payment trends for open (Current Procedural Terminology [CPT] code 43130) and endoscopic (CPT code 43180, introduced in 2015) repair of Zenker's diverticulum were analyzed, with reimbursement rates adjusted for inflation using the Consumer Price Index (CPI). Linear regression analysis was performed to assess the relationship between reimbursement rates and time.ResultsFrom 2000 to 2022, the total number of Zenker's diverticulectomy procedures decreased by 14.8% (1775–1513), with a 72.1% decrease (1775–495) for open approach. There was a 22.5% increase (831–1018) in endoscopic approach from 2015 to 2022. By 2022, endoscopic procedures accounted for 67.3% of all Zenker's diverticulectomies, compared to 32.7% for the open approach. From 2000 to 2024, inflation‐adjusted reimbursement for open procedures declined by 49.96% ($1586.26–$670.41), with an annual decrease of 2.08%. Endoscopic procedures, tracked separately from 2015 to 2024, saw a 29.32% decline ($773.24–$547.13) and an annual decrease of 3.26%. Unadjusted reimbursement for both approaches combined declined by an average of 0.88% per year, while inflation‐adjusted rates decreased by 3.45% annually (p < 0.001).ConclusionThere has been a downward trend in the Medicare reimbursement of Zenker's diverticulectomy, with an average adjusted decline of 3.45% annually. This trend raises concerns about the sustainability of such specialized procedures, potentially limiting access for elderly patients reliant on Medicare coverage.Level of Evidence4.

The Stag Beetle (SB) knife junior endoscopic scissors are commonly used in submucosal dissections. Its small size allows for more precise cuts that can be useful in diverticula with short, wide septa. In these types of septa, a Z-POEM technique may be considered, although its practicality is limited due to its complexity. We present the case of a 64-year-old man with symptoms of dysphagia, diagnosed with a 2 cm deep Zenker's diverticulum. It was therefore decided to perform an endoscopic muco-myotomy of the diverticulum.

Endoscopic treatment of Zenker's diverticulum: how can the size affect the selection of the technique?

Zenker's diverticulum (ZD) is an esophageal condition that results in an outpouching of the mucosal layer through a weakened area in the hypopharyngeal wall. This condition can cause symptoms like dysphagia, regurgitation, and aspiration, impacting patients' quality of life. Historically, open surgery was the primary treatment. Although effective, this method is associated with longer recovery times and risks such as infections, nerve damage, and prolonged hospitalization. Rigid endoscopic stapling emerged as a less invasive alternative, offering high success rates for patients with favorable anatomy. Zenker's peroral endoscopic myotomy (Z-POEM), adapted from treatments for achalasia, represents the latest advancement in ZD management. It involves creating a submucosal tunnel and precisely dividing the cricopharyngeus muscle. Z-POEM is minimally invasive and often provides quick relief with a high success rate of around 92%, while enabling outpatient treatment or brief hospital stays. However, it requires specialized expertise, and long-term data on recurrence rates are still emerging. This review discusses the evolution of these treatment modalities through comprehensive searches of PubMed, MEDLINE, and ScienceDirect databases. Studies reporting on treatment outcomes, complication rates, operative times, and clinical success associated with open surgery, rigid endoscopic stapling, and Z-POEM were included, with emphasis on meta-analyses, multicenter studies, and large case series highlighting Z-POEM's comparable success to open surgery and increased patient tolerance. Open surgery achieves long-term symptom resolution rates of 90-95% but is associated with higher complication rates (up to 30%) and prolonged recovery times. Rigid endoscopic stapling offers symptom relief in approximately 90% of cases, with lower morbidity and shorter hospital stays (1-2 days), though anatomical limitations restrict its use. Z-POEM has demonstrated clinical success rates of 85.5-93%, with major complications reported in 4.8-5% of cases and recurrence rates as low as 1.4% at one-year follow-up in larger diverticula. Z-POEM's minimally invasive nature and suitability for high-risk patients make it increasingly preferred in specialized centers. Management of Zenker's diverticulum has evolved significantly, with endoscopic techniques, particularly Z-POEM, offering comparable success to open surgery but with fewer complications and faster recovery. Ongoing advances in endoscopic equipment and technique, along with emerging data on long-term outcomes, are likely to further refine treatment algorithms for ZD, especially for elderly and high-risk populations. Future directions in ZD management include ongoing research to enhance the safety and efficacy of endoscopic techniques, with new technologies on the horizon that could further improve outcomes and accessibility.

Adjunctive resection of residual mucosal flap during Z-POEM for large Zenker's diverticulum.

ABSTRACTObjectivePatients with cricopharyngeus muscle dysfunction (CPMD) with and without diverticula (e.g., Zenker Diverticulum) often struggle with dysphagia for years prior to diagnosis or intervention. Surgical treatment is successful; yet, there is limited long‐term data on dysphagia outcomes after surgery.MethodsIndividuals prospectively enrolled in the Prospective Outcomes of Cricopharyngeal Hypertonicity (POuCH) collaborative with and without diverticula who underwent surgery from November 2014 to August 2024 and had at least 12 months of follow‐up were included. Eating Assessment Tool 10 (EAT10) was used to characterize patient‐reported outcomes. Descriptive statistics were performed using means, frequencies, and spaghetti plots.ResultsOf 164 patients initially identified, 2 withdrew and 2 were excluded for incomplete data; 160 were included. 31% were women, with a mean (SD) age of 70.1 (11.5). Endoscopic surgery (113, 71%) was more common than open technique (47, 29%). 19.4% of patients had undergone previous surgery. Postoperatively, patients were found to have improved EAT‐10 scores, with smaller changes recorded after 36 months. Median change in EAT‐10 compared to preoperative score was −12 points [IQR: −18, −5] at 12 months. 39 (24%) patients were followed for > 24 months (median change −11 [IQR: −14, −7]); 26 (16%) > 36 months (−9.5 [−17, −5]), and 12 (7.5%) > 48 months (−4 [IQR: −18, 4]). Six patients died during the study period.ConclusionImproved dysphagia after surgery appears stable with minimal change over time. Most patients (96.3%) survive at least 1 year. Surgical intervention for patients with CPMD with or without diverticula is an effective and reliable treatment option.Level of Evidence4.

Peroral Endoscopic Myotomy has been adapted for the treatment of Zenker's diverticula (ZD). Endoscopic suturing for ZD has shown early promise as an alternative treatment modality for large ZD. Currently, there are no long-term studies that aim to compare long-term outcomes of patients undergoing Z-POEM and endoscopic suturing for large ZD. This study was undertaken to determine the long-term outcomes of patients undergoing Z-POEM and Z-POEM with endoscopic suturing at a single institution. A retrospective review of a prospectively maintained gastroesophageal database was performed for all patients undergoing Z-POEM with standard closure of the mucosal defect with clips and Z-POEM with endoscopic suturing at a single institution. Demographic data, outcomes, and quality of life scores were analyzed and compared between groups with the Kruskal-Wallis test. From 2014 to 2024, 75 patients underwent endoscopic treatment for ZD. Z-POEM for ZD ≤ 4cm (N = 62), Z-POEM for ZD > 4cm (N = 9), and Z-POEM with endoscopic suturing for ZD > 4cm (N = 4). The overall technical and clinical success rates were 100% and 89.5%, respectively. A higher proportion of patients undergoing Z-POEM for ZD > 4cm had more post-operative interventions compared to those undergoing Z-POEM for ZD ≤ 4cm (p = 0.002). Interventions included endoscopic suturing, redo Z-POEM, and endoscopic fistula closure. No patients with ZD > 4cm who underwent Z-POEM with endoscopic suturing required post-operative interventions. No patients who underwent endoscopic suturing for large ZD had any complications or required any postoperative interventions. The Z-POEM > 4cm group had worse Dysphagia scores 6months postoperatively. Patients with ZD > 4cm who undergo Z-POEM with clip closure are more likely to undergo postoperative interventions due to persistent symptoms. Z-POEM with endoscopic suturing provides a safe and effective alternative treatment option for such patients.

The Impact of Frailty on Short-Term Outcomes After Surgery for Zenker Diverticulum.