Submucosal INjection-Guided Septomyotomy (SING technique)- a new approach for the endoscopic management of Zenker Diverticulum: Results from a Large Multicentric Italian Study

Aims Endoscopy is the first approach for managing Zenker's Diverticulum (ZD). Various techniques are available, each with specific advantages and limitations. We have developed a modified technique, termed Submucosal INjection-Guided septomyotomy (SING technique), to enhance the effectiveness of traditional endoscopic septotomy

Methods We performed a retrospective analysis of prospectively collected data on all consecutive ZD patients treated with SING technique at three Italian hospitals: San Raffaele Hospital, Niguarda Hospital and San Giovanni Bosco Hospital. SING procedure includes a classic septotomy, a mucosal incision with a Hook-Knife along the midline of the septum, and a cricopharyngeal myotomy extending along the entire length of the diverticulum and at least 10mm into the esophageal muscular layer. During septotomy, a submucosal injection is performed on both the esophageal and diverticular sides, enhancing visualization of the muscular layer and guiding a complete myotomy. This represents the innovative aspect of the technique and an improvement over the traditional septotomy. Clinical success (CS) was defined as a Kothari-Haber Score (KHS) of<2 at 3 months. Recurrence was defined as an increase in KHS of≥2 after CS. Follow-up assessments were conducted at 3 and 6 months, and then annually. Adverse Events (AEs) were classified according to the AGREE Classification.

Results Between October 2019 and August 2024, 102 patients with ZD underwent the SING procedure (median age 74 [IQR 68-81], 69.7% males). The median diverticula depth was 30mm (IQR 25-40) with a median septum length of 16mm (IQR 15-20). Median KHS at diagnosis was 4 (IQR 3-6) with a median symptom duration of 13 months (IQR 9-24). Technical success was achieved in all cases, and CS was observed in 98% of patients. Two cases of clinical failure were successfully treated with a re-do SING procedure. The median procedural time was 30 minutes (IQR 25-45), and the median hospital stay was 1 day (IQR 1-2). AEs included 2 cases of intraoperative bleeding and 1 case of perforation, all successfully treated endoscopically (IIIa). After a median follow-up of 370 days (IQR 297-747), recurrence was observed in 5% of patients [median time to recurrence of 204 days (IQR 154-443)], mostly managed repeating SING procedure.

Conclusions The SING technique is safe and effective for the endoscopic treatment of ZD. It improves upon the efficacy of traditional endoscopic septotomy and may also serve as a rescue therapy.