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Letter to the Editor Comments on 'Flexible endoscopic treatment of Zenker’s diverticulum: a retrospective study in a single center from Turkey'
Hye Kyung Jeonorcid, Gwang Ha Kimorcid

DOI: https://doi.org/10.5946/ce.2025.003
Published online: April 7, 2025

Department of Internal Medicine, Pusan National University School of Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan, Korea

Correspondence: Gwang Ha Kim Department of Internal Medicine, Pusan National University School of Medicine and Biomedical Research Institute, Pusan National University Hospital, 179 Gudeok-ro, Seo-gu, Busan 49241, Korea E-mail: doc0224@pusan.ac.kr
• Received: January 3, 2025   • Revised: January 25, 2025   • Accepted: January 30, 2025

© 2025 Korean Society of Gastrointestinal Endoscopy

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.

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See the article "Flexible endoscopic treatment of Zenker’s diverticulum: a retrospective study in a single center from Turkey" on page 261.
Zenker’s diverticulum (ZD) is a rare but clinically significant condition characterized by dysphagia and increased aspiration risk. Although traditionally managed with open surgery, treatment modalities have shifted toward minimally invasive endoscopic techniques that reduce adverse events and offer faster recovery. Kenarli and Ödemiş’s study1 on flexible endoscopic septal division (FESD) reveals valuable insights, showing a 100% clinical success rate and a 20% recurrence rate. These findings support the effectiveness and safety of FESD, strengthening the growing consensus that flexible endoscopy is the preferred approach for ZD management.2
FESD is superior to open surgical and rigid endoscopic approaches due to its minimal invasiveness and adaptability to patient-specific needs. The use of a custom diverticuloscope in this study highlights practical innovations that can improve outcomes while maintaining procedural safety.1 The emphasis on reducing recurrence through meticulous technique and close follow-up is driving the evolution of endoscopic practices. However, recurrence remains a concern, and elucidating its post-procedure predictors is important. Factors including incomplete septotomy and residual diverticular depth contribute to recurrence, suggesting a need for more advanced techniques such as ZD per-oral endoscopic myotomy (Z-POEM).3
Recent technical advances, including Z-POEM and submucosal tunneling endoscopic septum division, provide promising alternatives to FESD, particularly in complex cases. Dell'Anna et al.4 highlighted the advantages of Z-POEM in preserving mucosal integrity and reducing recurrence rates. Sato et al.5 also emphasized patient-specific approaches, noting that shorter septa or anatomical constraints may favor newer techniques such as per-oral endoscopic septotomy. These innovations enable more precise septal division while minimizing injury, thus addressing some limitations associated with traditional FESD.
The use of flexible endoscopy to treat older patients with significant comorbidities offers particular advantages. The repeatability of this procedure for recurrent cases provides an advantage over surgical approaches, as demonstrated by successful reintervention in this study.1 Despite these benefits, the need for procedural standardization remains critical. Currently used devices, while effective, should be complemented with efforts to establish standard protocols that increase inter-center reproducibility and outcomes.
Comparative studies are essential to optimize the endoscopic technique for ZD management. While FESD remains the cornerstone, newer approaches such as Z-POEM may offer better outcomes in specific patient populations. Prospective multicenter trials focusing on safety profiles, recurrence rates, and cost-effectiveness will help validate the treatment algorithms. Innovations in preprocedural imaging, including functional lumen imaging probes, may further optimize patient selection and procedural planning.
In conclusion, flexible endoscopic treatment has been established as the standard treatment modality for ZD owing to its high success rate, safety, and feasibility. The future of ZD management lies in the integration of advanced techniques, such as Z-POEM, and the incorporation of procedural refinements and evidence-based protocols.
  • 1. 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.ArticlePubMed
  • 2. Nabi Z, Reddy DN. Submucosal endoscopy: the present and future. Clin Endosc 2023;56:23–37.ArticlePubMedPMCPDF
  • 3. Miutescu BP, Khan S, Mony S, et al. Role of peroral endoscopic myotomy (poem) in the management of esophageal diverticula. Clin Endosc 2020;53:646–651.ArticlePubMedPMC
  • 4. Dell'Anna G, Fasulo E, Fanizza J, et al. The endoscopic management of Zenker's diverticulum: a comprehensive review. Diagnostics (Basel) 2024;14:2155.ArticlePubMedPMC
  • 5. Sato H, Takeuchi M, Hashimoto S, et al. Esophageal diverticulum: new perspectives in the era of minimally invasive endoscopic treatment. World J Gastroenterol 2019;25:1457–1464.ArticlePubMedPMC

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