Purnima Bhat; Nicholas G. Burgess

doi:10.5946/ce.2025.038

Articles

Page Path: HOME > Clin Endosc > Volume 58(2); 2025 > Article

Editorial Endoscopic management of hypopharyngeal diverticulum: septotomy versus Zenker’s diverticulum per-oral endoscopic myotomy?: Purnima Bhat^1,2, Nicholas G. Burgess^3,4; Clinical Endoscopy 2025;58(2):253-255.
DOI: https://doi.org/10.5946/ce.2025.038
Published online: March 24, 2025

¹Gastroenterology and Hepatology Unit, Canberra Hospital, Canberra, ACT, Australia

²School of Medicine and Psychology, Australian National University, Canberra, ACT, Australia

³Department of Gastroenterology and Hepatology, Westmead Hospital, Sydney, NSW, Australia

⁴Westmead Clinical School, University of Sydney, Sydney, NSW, Australia

Correspondence: Purnima Bhat Gastroenterology and Hepatology Unit, Canberra Hospital, Yamba Drive, Garran, 2605, ACT, Australia E-mail: purnima.bhat@anu.edu.au

• Received: February 6, 2025 • Revised: February 8, 2025 • Accepted: February 9, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

231 Views
41 Download

prev next

Full Article

Download PDF

NOTES
REFERENCES

See the article "Flexible endoscopic treatment of Zenker’s diverticulum: a retrospective study in a single center from Turkey" on page 261.

Hypopharyngeal Zenker’s diverticulum (ZD) is rare and usually occurs in the elderly, potentially severely impacting the quality of life for patients who may be already frail. It causing dysphagia, regurgitation, chronic cough, and aspiration pneumonia.¹ The diverticulum typically develops in the weak area of the posterior hypopharynx, known as the Killian’s triangle (between the thyropharyngeus and cricopharyngeal muscle fibers of the inferior constrictor).² Although its true prevalence is unknown, it is occasionally seen as an incidental finding during upper gastrointestinal endoscopy. Only 0.01% to 0.11% of patients present with symptomatic diverticula. Dysphagia is often multifactorial, especially in the elderly population; therefore, careful workup is required, as swallowing incoordination and/or esophageal dysmotility may coexist.

Treatment is indicated for symptomatic diverticula and requires complete division of the cricopharyngeus muscle to obliterate the pouch. Open surgery is a traditional treatment with reported clinical success rates of 94% to 96%; however, it is invasive and has an 11% to 15% adverse event rate.³^,⁴ Rigid endoscopy is a similarly effective alternative that is less invasive with shorter recovery times, but it requires significant neck hyperextension, contributing to technical failure in 6% to 7% of elderly patients.⁴ Flexible endoscopy techniques offer comparable efficacy to surgical and rigid endoscopy approaches while being minimally invasive with low adverse event rates, an important consideration in an elderly, comorbid population. Based on these efficacy and safety considerations, the European Society of Gastrointestinal Endoscopy guidelines suggest flexible endoscopic treatment as the first-line therapy for symptomatic hypopharyngeal diverticula.²

Attention has now turned to which the flexible endoscopic technique is best suited for ZD. The decades-old “tried-and-true” flexible endoscopic septotomy (FES) is the best studied. This technique involves direct incision of the septum using a needle knife or, more recently, electrosurgical knives used for endoscopic submucosal dissection. The septum is divided to the base of the diverticulum; then, the defect is either left open, or one or more clips may be placed for closure. A nasogastric tube or wire in the esophageal lumen can aid in orientation and access. A specially designed overtube or “diverticuloscope” may be preferred to stabilize the septum and prevent esophageal wall injury. Although FES is well established, there is significant variation in the technique, and some endoscopists may not completely identify, expose, and divide the cricopharyngeus. The reported outcomes of FES can vary; however, in a meta-analysis of nine studies (759 patients) by Delgado et al.,⁵ pooled clinical success rates of approximately 75% were reported, adverse event rates were 10.2% (major adverse events, 3.7%), and recurrence was 17%.⁵

In contrast to FES, the “new-kid-on-the-block”, ZD per-oral endoscopic myotomy (Z-POEM) has gained attention. The effectiveness and safety of POEM for esophageal motility disorders have been definitively demonstrated, and it is well-suited for the treatment of ZD. Z-POEM is performed by creating a submucosal cushion over, or slightly proximal to, the septum, followed by tunnelling on the esophageal and diverticular sides to expose the cricopharyngeal muscle. The cricopharyngeus and 1 to 2 cm of the upper esophageal muscle are then completely cut, with the tunnel aiding control and contrast dye in the submucosal injectate improving visualization. Upon completion, the tunnel entry was closed using clips. Z-POEM is more likely to allow complete cricopharyngeal division but may result in a persistent mucosal flap. A meta-analysis by Delgado et al.⁵ showed that the pooled clinical success rate was 87.4%, adverse events occurred in 14.0% of patients (major adverse events, 6.6%), and the clinical recurrence rate was 10.3%. The studies were small, retrospective series with some heterogeneity. However, when compared with FES, the outcomes were similar, although the initial clinical success rate was higher after Z-POEM.⁶ A retrospective head-to-head comparison between FES without closure and Z-POEM reported similar clinical success and recurrence rates with fewer hospitalizations following Z-POEM.⁷

Large sized lesions of >50 mm are associated with early clinical recurrence after FES.⁸ However, a recent retrospective multicenter analysis of Z-POEM for large diverticula (≥40 mm) has shown excellent outcomes, with clinical success in 85.5% and recurrence in only 1.4% at 12 months.⁹

In this context, Kenarli and Ödemiş¹⁰ offer their experience of FES in this issue of Clinical Endoscopy, describing a retrospective series of 15 patients treated by a single operator using a needle knife, diverticular overtube and clip closure of the defect. The diverticula size ranged 20 to 68 mm, as measured using a marked endoscopic retrograde cholangiopancreatography catheter that guided the cutting depth rather than visualization of the cricopharyngeus muscle. The clinical success rate was 100%, as defined by a 2-point decrease in the modified Eckhardt score. One patient (6.25%) developed a fever, which was managed conservatively. Clinical recurrence occurred in three patients (20%). One patient underwent retreatment with FES, one with Z-POEM, and one with surgery.

Although this was a small series, the outcomes were consistent with the established data for the FES. The clinical recurrence rate of 20% is higher than expected and may reflect a possible incomplete division of the cricopharyngeus when using diverticular depth as an endpoint for completion; however, with such a small sample size, it is difficult to confirm that this is truly outside the expected range. Antibiotics were routinely administered in this study; however, the utility of prophylactic antibiotics has not been proven and is currently not recommended.²

This study adds to worldwide data and confirms that FES is an effective and reliable treatment for hypopharyngeal diverticula, offering low recurrence rates and few complications. FES or Z-POEM techniques may be used depending on local expertise. However, care and skill are always required, as even though adverse events are uncommon, perforation and mediastinitis can occur and be severe, particularly in elderly and comorbid patient groups. Initial clinical success rates appear to be higher with Z-POEM, perhaps because this technique offers the advantage of complete myotomy under visualization. Endoscopists performing FES with low clinical success could consider moving to Z-POEM or a hybrid approach to improve outcomes. As international experience grows, the lessons learned will inform adaptations to both techniques, which are likely to improve safety and outcomes. A customized approach with careful patient evaluation utilizing either technique with locally available expertise will lead to excellent outcomes by improving patient nutrition, minimizing risk, and improving the quality of life.

Conflicts of Interest

Nicholas G. Burgess received lecture fees (Boston Scientific). The other author has no potential conflicts of interest.

Funding

None.

Author Contributions

Conceptualization: PB, NGB; Writing–original draft: PB; Writing–review & editing: all authors.

REFERENCES

1. Ferreira LE, Simmons DT, Baron TH. Zenker's diverticula: pathophysiology, clinical presentation, and flexible endoscopic management. Dis Esophagus 2008;21:1–8.Article PubMed
2. Weusten BLAM, 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.Article PubMed
3. Howell R, Johnson C, Allen J, et al. Surgical Outcomes in Zenker diverticula: a multicenter, prospective, longitudinal study. Laryngoscope 2024;134:97–102.Article PubMed
4. Verdonck J, Morton RP. Systematic review on treatment of Zenker's diverticulum. Eur Arch Otorhinolaryngol 2015;272:3095–3107.Article PubMed PDF
5. Delgado LM, Meine GC, Santo P, et al. Endoscopic submucosal tunneling techniques versus flexible endoscopic septotomy for Zenker's diverticulum: a systematic review and meta-analysis. Gastrointest Endosc 2024:S0016-5107(24)03753-2.Article PubMed
6. 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.Article PubMed PDF
7. Sarkis Y, Stainko S, Perkins A, et al. Comparison of flexible endoscopic needle-knife septotomy and peroral endoscopic myotomy for treatment of Zenker's diverticulum. Gastrointest Endosc 2025;101:82–89.Article PubMed
8. 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.Article PubMed
9. Zhang LY, Hernández Mondragón O, et al. Zenker's peroral endoscopic myotomy for management of large Zenker's diverticulum. Endoscopy 2023;55:501–507.Article PubMed
10. Kenarli K, Ödemiş B. Flexible endoscopic treatment of Zenker's diverticulum: a retrospective study in a single center from Turkey. Clin Endosc 2025;58:261–268.Article PubMed

Figure & Data

REFERENCES

Citations

Citations to this article as recorded by

PubReader
ePub Link

Cite

CITE: export Copy Download Format; Close

Download Citation

Download a citation file in RIS format that can be imported by all major citation management software, including EndNote, ProCite, RefWorks, and Reference Manager.