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

We read with great interest the study by Almario et al. reporting excellent clinical and technical success rates for modified Zenker’s diverticulum peroral endoscopic myotomy (Z-POEM) with mucosal flap incision (MFI) [1]. Their results add to the expanding evidence supporting advanced endoscopic techniques for managing symptomatic Zenker’s diverticulum and establishing a novel approach potentially reducing post-procedure symptom recurrence. We would like to share a few comments based on our experience with Z-POEM with MFI in large diverticula [2].

In the Almario et al. study, Z-POEM with MFI was performed on patients with both small and large diverticula (mean size 3.2 cm), demonstrating high efficacy and safety [1]. In contrast, our series focused on patients with large diverticula (mean size 5.1 cm), where technical challenges, incomplete myotomy risks, and redundant mucosal flap are greater [2]. Despite similar clinical success between Z-POEM with MFI and flexible endoscopic myotomy (FES) in patients with diverticula >4 cm, we agree that in a larger cohort, Z-POEM with MFI may prove particularly beneficial in this subgroup with high risk of poor clinical outcomes, owing to its technical advantage for deep enough myotomy.

However, we question the cost-effectiveness of these modifications in small diverticula. Compared with FES, the cumulative cost of Z-POEM with MFI is greater, requiring two knives, multiple clips, and longer procedure times (11 vs. 102 minutes). As the clinical recurrence risk is comparable between FES and Z-POEM, the additional complexity may not be justified in all cases [3] [4] [5].

Therefore, we believe a tailored approach is warranted. While Z-POEM with MFI may provide clinical benefit in large diverticula, simpler and less costly options may suffice for smaller ones. Prospective, comparative studies are needed to clarify the optimal approach across the spectrum of Zenker’s diverticulum, considering not only efficacy but also cost, safety, and procedural simplicity and feasibility.

Publikationsverlauf

Artikel online veröffentlicht:
28. August 2025

• References

• 1 Almario JA, Mehta A, Shrigiriwar A. et al. Short-term clinical and technical outcomes of a modified Zenker’s peroral endoscopic myotomy with mucosal flap incision. Endoscopy 2025; 57: 348-353
• 2 Tribonias G, Dimopoulou K, Zormpas P. et al. eP584 Prospective comparison of Z-POEM + Mucosectomy (Z-POEM + M) with flexible endoscopic septotomy (FES) in large (>4cm) zenker’s diverticula. Endoscopy 2025; 57: s489
• 3 Al Ghamdi SS, Farha J, Moran RA. et al. Zenker’s peroral endoscopic myotomy, or flexible or rigid septotomy for Zenker’s diverticulum: a multicenter retrospective comparison. Endoscopy 2022; 54: 345-351
• 4 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 2025; 101: 751-761 e730
• 5 Spadaccini M, Maselli R, Chandrasekar VT. et al. Submucosal tunnelling techniques for Zenker’s diverticulum: a systematic review of early outcomes with pooled analysis. Eur J Gastroenterol Hepatol 2021; 33: e78-e83