Comparison of standard flexible endoscopic septotomy with Zenker’s peroral endoscopic myotomy/septotomy for Zenker’s diverticulum: a dual-center retrospective study

Aims To analyze the clinical outcomes of endoscopic treatment for Zenker's diverticulum between flexible endoscopic septotomy and Zenker-Peroral Endoscopic Myotomy (Z-POEM) or Peroral Endoscopic Septotomy (POES) in two Spanish hospitals.

Methods A dual-center, retrospective, observational study based on prospectively collected data. Reviewed period: 2010–2024. Main outcome: Clinical success defined as validated Kothari Haber Score System (KHSS)<3 at first visitation and no reintervention<6 months. Secondary outcomes : Demographics, baseline symptoms, technical success, safety (AGREE classification) and recurrence with or without reintervention. All procedures were done under general anesthesia.

Results Inclusion of 59 patients (61% male, mean age 74.9 [SD 7.9], 84.8% with intermediate anesthesic risk [ASA 2-3, median Charlson Comorbidity Index 4, IQR 2]) and 77 procedures (63 septotomies, 14 Z-POEM/POES [including one distal diverticulum]). Predominant symptoms: dysphagia (96%) and regurgitation (84%). Baseline KHSS median 5, IQR [4–6] and modified Dakkak-Bennet score: 2 IQR [1-2,75], without differences between both groups(P=0.8 and P=0.49 respectively). Z-POEM/POES was performed using a Flush Knife; median tunnel length 20 mm, IQR[20-32.5]. Clinical success: septotomy 83,1% and Z-POEM 92.9%, no significant differences (P=0.36). Technical success: 97% in septotomy and 100% in Z-POEM/POES. Safety: Overall AEs: 19.5%. Septotomy group: 16% (6/63 fever including 2 perforations managed with antibiotics [II] and endoscopic reintervention [IIIa] involving an extrahospitalization stay, 2/63 bleeding [I]). Z-POEM/POES: 36% (5/14), all of them subcutaneous emphysema (1[I], and 4[II] managed with antibiotics and longer hospitalization); no statistical differences in percentage (P=0.08) neither hospitalization stay (P=0.16) per group. Clinical outcomes: improvement at the first follow-up 88.% septotomy and 100% Z-POEM group with a median KHSS of 0, IQR [0–1] and in both groups. Clinical recurrence (KHSS>2): observed in 33% of patients, with endoscopic reintervention in 13/46 (28%) patients in septotomy group, 11/13 who underwent repeat septotomies (≥ 1) and 2/13 underwent Z-POEM/POES (following 2 prior septotomies); with only 1 patient (8%) who needed a second Z-POEM/POES in the other group, without statistical differences (P=0.15).

Conclusions Standard flexible Endoscopic septotomy and Z-POEM/POES appear to provide similar clinical outcomes. The reintervention rate is considerable for flexible septotomy group. Prospective studies with long-term follow-up are required [1] [2] [3] [4] [5] [6].

Publication History

Article published online:
27 March 2025

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