| Zenker's diverticulum (ZD) is a sac-like outpouching of the mucosa and submucosa of Killian's triangle within the pharyngoesophageal junction. Common symptoms include progressive oropharyngeal dysphagia, regurgitation and halitosis, with complications including aspiration pneumonia, bleeding and ulceration from medication and food retention, as well as malnutrition. The management of ZD traditionally involved open surgical and rigid endoscopic repair, but for many years flexible endoscopic Zenker's diverticulotomy (EZD) has been successfully performed as a safe and effective alternative with similar clinical outcomes and decreased morbidity. EZD involves septal myotomy, targeting the cricopharyngeal muscle that acts as a barrier separating the ZD from the esophagus. With the advent of third space endoscopy, per-oral endoscopic myotomy (POEM) techniques have been applied to the treatment of Zenker's diverticulum, giving rise to a novel Z-POEM technique. This approach involves creating a mucosal entry point directly above the septum of the ZD, which provides immediate access to the cricopharyngeal muscle through a submucosal tunneling approach, allowing for deep cricopharyngeal dissection to below the base of the ZD. Consequently, this necessitates complete closure of the mucosal incision, which means a portion of the mucosal flap must be preserved. While the emergence of the Z-POEM technique generated tremendous enthusiasm amongst advanced endoscopists, it remains unclear whether it results in superior outcomes in terms of successful clinical response or reduced long-term recurrence in comparison to EZD. The aim of this lecture is to compare the technical aspects, clinical efficacy and safety of the EZD and Z-POEM techniques, and to offer insight as to what the best approach may be for both short and long ZD. |
