Comparative Analysis of Z-POEM and Flexible Endoscopic Septotomy for symptomatic Zenker’s Diverticulum

Aims Nowadays, endoscopic treatment for esophageal Zenker's diverticulum is considered the standard of care, with flexible endoscopic septotomy (FES) being the first technique to be widely adopted. Since 2016, submucosal tunneling Per-Oral Endoscopic Myotomy (Z-POEM) has emerged as an innovative therapeutic approach. However, medium-term efficacy comparisons between Z-POEM and FES remain limited. The aim of this study was to compare the clinical success and safety of Z-POEM and FES.

Methods This study was a retrospective analysis of a large group of patients treated for Zenker's diverticulum across two tertiary care centers. The patients were divided into two groups: those who underwent Z-POEM between 2021 and 2024, and those who underwent FES between 2008 and 2024. Demographic and clinical data, including Charlson Comorbidity Index, Kothari scores, clinical success rates, adverse events, and follow-up duration, were analyzed and compared among the two groups [1] [2] [3] [4].

Results Sixty-six patients affected by Zenker’s diverticulum underwent endoscopic treatment in the study period. Of these, 32 patients (mean age 66.8±10.7 years) underwent Z-POEM, while 34 patients (mean age 73.5±10.2 years) underwent FES. The mean Charlson Comorbidity Index was similar between groups (Z-POEM: 3.28±1.80 vs. FES: 3.4±1.6; p=0.708). The pre-procedural Kothari-Haber score was comparable (mean 7.3±1.4 for Z-POEM vs. 7.3±1.1 for FES; p=0.981). The post-procedural Kothari-Haber score was significantly lower in the Z-POEM group (1.3±1.3) compared to the FES group (2.7±2.8; p=0.010), indicating better symptom resolution. The median follow-up period was 37.7 months (IQR: 14.8 – 74.6 months) for the FES group and 12.2 months (IQR: 7.4 – 21.9 months) for the Z-POEM group (p<0.0001). Technical success was achieved in 100% in both groups. Clinical success was significantly higher in the Z-POEM group (93.8%; 95% CI: 75% – 99%) compared to the FES group (64.5%; 95% CI: 50% – 82%; p=0.005). The rate of adverse events was lower in the Z-POEM group (6.25%) compared to the FES group (23.53%), however this difference did not reach statistical significance (p=0.084).

Conclusions This multicenter retrospective study suggests that Z-POEM is an effective and safe alternative to FES for the treatment of Zenker’s diverticulum. The Z-POEM technique demonstrated a significantly higher clinical success rate and a trend towards fewer adverse events. Of particular interest, no differences in terms of efficacy and adverse events were observed between the first 10 patients (during the learning curve) treated with Z-POEM and those treated thereafter. It should be noted that although the follow-up period for Z-POEM was generally shorter, no recurrence of symptoms was observed even in patients with longer follow-up durations. These findings support the use of Z-POEM as a viable and effective approach, warranting further investigation in larger multicenter cohorts to confirm its advantages [5].

 

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Conflicts of Interest

G. Grande is a consultant for Olympus, ERBE, Boston Scientific

• References

• 1 Bizzotto A, Iacopini F, Landi R, Costamagna G.. Zenker's diverticulum: exploring treatment options. Acta Otorhinolaryngol Ital 2013; 33 (04): 219-29 PMID: 24043908; PMCID: PMC3773964.
• 2 Elkholy S, El-Sherbiny M, Delano-Alonso R, Herrera-Esquivel JJ, Valenzuela-Salazar C, Rodriguez-Parra A, Del Rio-Suarez I, Vargas-Madrigal J, Akar T, Günay S, Houmani Z, Abayli B, Elkady MA, Alzamzamy A, Wahba M, Madkour A, Mahdy RE, Essam K, Khashab MA.. Peroral endoscopic myotomy as treatment for Zenker's diverticulum (Z-POEM): a multi-center international study. Esophagus 2021; 18 (03): 693-699 Epub 2021 Jan 2. PMID: 33387150.
• 3 Kahaleh M, Mahpour NY, Tyberg A, Bareket R, Shahid HM, Sarkar A, Abdelqader A, Gjeorgjievski M, Marino D, Kats D, Gaidhane M, Greenberg I, Lee DP, Bushe B, Eke C, Sun H, Kedia P, Méndez ALM, Lambroza A, Barret M, Hallit R, Eleftheriadis NP, Nieto J, Oleas R, Robles-Medranda C, Bapaye A.. Per Oral Endoscopic Myotomy for Zenker's Diverticulum: A Novel and Superior Technique Compared With Septotomy?. J Clin Gastroenterol 2022; 56 (03): 224-227 PMID: 34183618.
• 4 Steinway S, Zhang L, Amundson J, Nieto J, Desai P, Jacques J, Bejjani M, Pioche M, Kumta N, Hernandez-Mondragon O, Ujiki M, Khashab M.. Long-term outcomes of Zenker's peroral endoscopic myotomy (Z-POEM) for treatment of Zenker's diverticulum. Endosc Int Open 2023; 11 (06): E607-E612 PMID: 37397859; PMCID: PMC10310448
• 5 Swei E., Pokala S.K., Menard-Katcher P.. et al. Comparison of Zenker’s per-oral endoscopic myotomy (Z-POEM) with standard flexible endoscopic septotomy for Zenker’s diverticulum: a prospective study with 2-year follow-up. Surg Endosc 2023; 37: 6818-6823

Publication History

Article published online:
27 March 2025