Prospective comparison of Z-POEM+Mucosectomy (Z-POEM+M) with flexible endoscopic septotomy (FES) in large (> 4cm) zenker’s diverticula

Aims Flexible endoscopic treatment of Zenker’s diverticulum through submucosal tunneling (Z-POEM), similar to esophageal Per-Oral Endoscopic Myotomy (POEM), is gaining popularity. However, there is no data comparing Z-POEM with simultaneous mucosectomy (Z-POEM+M) of the remaining sac with traditional flexible endoscopic septotomy (FES) in large (> 4cm) diverticula according to Morton classification. This study aims to compare Z-POEM+M with FES regarding clinical success, technical success, adverse events (AEs), recurrence rates, procedural time and cumulative cost in large Zenker’s diverticula (> 4cm).

Methods A prospective study comparing Z-POEM+M and FES was conducted between 2021 and 2024 at two tertiary hospitals. The primary outcome was clinical success, defined as a reduction in the Dakkak and Bennett dysphagia score to 1, or to 0 for patients with a baseline score of 1, along with complete resolution of other symptoms for those without dysphagia at baseline. Secondary outcomes included technical success, rate of AEs, procedural time and cumulative cost.

Results 16 patients (mean age 69 years; 63% male) underwent traditional FES (8 pts) and Z-POEM+M (8pts). Mean size of diverticulum was 51±14 mm and 58±16 mm in FES and Z-POEM+M group respectively. There were no significant differences in baseline characteristics among the groups. The primary symptoms at the time of the procedure were dysphagia (81%) and regurgitation (69%). Clinical and technical success rates were 88% for FES and 100% for Z-POEM+M (p>0.9). One patient with a very large diverticulum (8 cm) treated with FES experienced incomplete septotomy without any improvement in dysphagia score and Eckardt score. The mean procedural time for FES (11±2 min) was significantly shorter than for Z-POEM+M group (102±25 min, p<0.001). The median length of stay was similar for FES and Z-POEM+M groups (2 days). Overall clinical success was 93.8% (15/16) and did not significantly differ between the groups (FES: 7/8, 88% vs Z-POEM+M: 8/8, 100%, p>0.9). Median follow-up time for FES group was 13±8 months and 13±9 for the Z-POEM+M group. No fatal AE demonstrated in both groups, while mild to moderate procedure-related AEs were reported in 4 patients (50%) in Z-POEM+M group and 1 (13%) in FES group (p=0.2). Cumulative cost of the procedure was half in FES group (median cost: 837 euros FES group vs 1560 euros Z-POEM+M group), because of the fewer knives (FES group: SB knife/Z-POEM+M group: Hook+SB knife) and fewer clips (median number: 2 clips FES group vs 7 clips Z-POEM+M group) used.

Conclusions Although Z-POEM+M and FES demonstrated similar clinical success in large (> 4cm) Zenker’s diverticula, FES turned out as a presumptive first-choice treatment procedure, because of significantly shorter procedural time and lower cost.

Publication History

Article published online:
27 March 2025