Performance of endoscopic approaches for Zenker diverticulum management: a systematic review and meta-analysis

Aims Zenker’s diverticulum is associated with a significant burden on quality of life and morbidity, predisposing to dysphagia, regurgitation and aspiration pneumonia. Surgery has been the preferred option historically due to a lack of alternative options but remains invasive with major potential complications. Endoscopic approaches offer a minimally invasive alternative treatment option including rigid and flexible diverticulotomy, and the emerging Zenker per-oral endoscopic myotomy (Z-POEM). This systematic review and meta-analysis aimed to summarize the efficacy and safety of these endoscopic techniques.

Methods A systematic search in Medline, Cochrane and Scopus databases was performed until November 2023. The primary outcome was technical success, defined as the completion of diverticulotomy/myotomy in one session. Secondary outcomes included clinical success which corresponded to the complete resolution of dysphagia or a post-procedure Dakkak and Bennett score≤1. Moreover, the recurrence rates and the overall adverse events were recorded. Subgroup analyses per outcome were performed to discriminate the results depending on the endoscopic approach (Rigid, flexible diverticulotomy and Z-POEM), whereas the comparative studies were meta-analyzed to compare Z-POEM with alternatives. We used a random effects model and the results were reported as percentages for pooled rates and odds ratios (OR) for comparative data with 95% Confidence Intervals (95% CIs).

Results Twenty-three studies (1357 patients; 40% female; mean age 43-80) were included in our analysis. The cumulative technical success rate was 97.7% (95% CI:96.9-98.5) with null heterogeneity (I²=0%), and this outcome was preserved in all subgroups. Considering clinical success, the overall pooled rate was 84.8% (95% CI:80.8-88.8;I²=79.15%) with Z-POEM yielding higher rate [90.4%(95% CI:87.8-93.1)] with low heterogeneity (I²=11%), in contrast to the alternatives. 8.6% (95% CI:6.0-11.3;I²:63.6%) of cases experienced recurrence, with those post-Z-POEM having the lowest rates [5.7%(95% CI:2.3-9.1;I²:55.68%)] and post-flexible myotomy the highest ones [12.1%(95% CI:8.0-16.2;I²=36.09%)]. Finally, complications occurred in 8.7% (95% CI:6.0-11.4; I2=78.08%) with no changes in subgroup analysis. Technical success and recurrence rates were similar between Z-POEM and alternatives [OR:1.38 (95% CI: 0.59-3.23, p=0.5; I2=0%) and OR:0.69 (95% CI: 0.29-1.51, p=0.39; I²=48.71%), respectively], whereas Z-POEM achieved higher clinical success rates [OR:2.38 (95% CI: 1.54-3.68, p<0.001; I²=0%)].

Conclusions Endoscopic treatment offers high technical success and symptom resolution in patients with Zenker diverticulum, with relatively low prevalence of adverse events and recurrence. Z-POEM offers higher clinical success rates compared to alternatives with optimal homogeneity.

 

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Conflicts of interest

Authors do not have any conflict of interest to disclose.

Publication History

Article published online:
15 April 2024