Post written by Harold Benites-Goñi, MD, from San Ignacio de Loyola University and Edgardo Rebagliati Martins National Hospital, Lima, Perú.

The final goal of treatment of Zenker’s diverticulum is cutting the cricopharyngeal muscle to eliminate the septum. In our video, we show a variant of peroral endoscopic myotomy for the management of Zenker’s diverticulum.

This case involves an 89-year-old man who was referred to our hospital with a diagnosis of Zenker’s diverticulum that was 3.5 cm long. The first step is to identify the center of the diverticular septum. After injection of diluted methylene blue, a mucosal incision is made that will later allow us to dissect both sides of the septum to its base with a CORE knife (INCORE, Daegu, South Korea; swift coagulation mode; effect 2 and 40 W).

By performing the myotomy under direct vision, we ensure that the muscular septum is completely cut (Fig. 4). After these steps, the flap is fixed with a clip on each side of the incision, and then the mucosal flap is cut on both sides perpendicular to the axis of the septum with an insulation-tipped knife (Olympus, Center Valley, Pa; Endocut Q current; effect 3, interval 1, and duration 1).

The final step is closure of the mucosal defect with clips, which is usually somewhat difficult, but with sequential closure, it is performed without much trouble.

The advantage of this novel technique is that Zenker’s peroral myotomy allows us to visualize the section of the muscular septum completely and, with addition of mucosotomy of the remaining mucosal flap after endoscopic myotomy, formation of a mucosal flap will be avoided. This mucosal flap can contribute to the persistence of dysphagia, especially in larger diverticula (>2 cm).

It is important to choose the best technique for each case. With Zenker’s diverticula >2 cm, we suggest adding cutting of the mucosal flap after peroral myotomy to prevent recurrence of symptoms. Likely the most complicated step is closing the mucosal defect with clips, so we suggest first fixing the flap with a clip on each side and using small clips to facilitate their placement.

Work should continue to develop better techniques for the endoscopic management of Zenker’s diverticula, and more studies—ideally, prospective and randomized—should be carried out to clarify the efficacy and safety of this variant of peroral endoscopic myotomy.

Diagram showing the placement of clips to stabilize the mucosal flap before mucosotomy.

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