Post written by Lucas Monteiro Delgado from the Universidade Federal de Minas Gerais, Belo Horizonte, and Gilmara Coelho Meine, MD, MSc, from the Division of Gastroenterology, Department of Internal Medicine, Feevale University, Novo Hamburgo, Brazil.

Zenker’s diverticulum is the most common type of esophageal diverticulum, predominantly affecting elderly men. Although its incidence is low, it is expected to rise with an aging population. The most frequent symptoms are dysphagia and regurgitation, and treatment is recommended at symptom onset, regardless of diverticulum size.

Among the available treatment options, flexible endoscopic septotomy (FES) is a well-established, minimally invasive technique that involves incision of the midline septum between the diverticulum and esophageal lumen. The incision typically extends nearly to the base of the diverticulum. However, as the septum is not completely excised, some patients may experience symptom recurrence.

Recent advances in interventional endoscopy have led to development of endoscopic submucosal tunneling techniques (ESTTs), such as Zenker’s peroral endoscopic myotomy and peroral endoscopic septotomy. These methods involve creating a submucosal tunnel to allow complete myotomy of the septum, a key prognostic factor for procedural success.

In this systematic review and meta-analysis of 9 studies including 759 patients, we compared the efficacy and safety of ESTTs versus FES for treatment of Zenker’s diverticulum. ESTTs were associated with a 15% higher rate of clinical success (RR, 1.15; 95% CI, 1.04-1.28; P < .01) and a nonsignificant trend toward lower clinical recurrence (RR. .56; 95% CI, .29-1.07; P = .08) compared with FES. Technical success, operative time, length of hospital stay, and adverse events were similar between the groups.

We also conducted subgroup analyses based on follow-up duration, diverticulum size, and ESTT among the included studies. The consistency of findings within these subgroups supports the robustness of the results. Our analysis suggests that ESTTs are safe and effective across different diverticulum sizes and endoscopic techniques, with benefits sustained beyond 12 months of follow-up.

Nonetheless, the broader adoption of ESTTs may be limited by the technical demands and limited availability of expertise in third-space endoscopy. Anatomical differences between the cricopharyngeal region and distal esophagus—where the peroral endoscopic myotomy technique was originally developed—pose additional challenges. The narrower lumen of the proximal esophagus and absence of a muscular layer at the hypopharyngeal level may contribute to increased procedural complexity and a longer learning curve.

In conclusion, this systematic review and meta-analysis of observational comparative studies indicated that ESTTs were associated with increased clinical success and showed a trend toward lower clinical recurrence than with FES, making them a safe and effective alternative for treating Zenker’s diverticulum. However, randomized controlled trials are necessary to confirm these findings.

Endoscopic submucosal tunneling techniques. A, Z-POEM technique. Submucosal injection and mucosotomy are performed 1 to 2 cm proximal to the septum, followed by esophageal submucosal dissection from the incision site to the Zenker’s diverticulum septum, with subsequent dissection along both sides of the septum. B, POES technique. Submucosal injection and mucosotomy are performed directly over the septum, allowing for more direct access to submucosal dissection and exposure of the septum. C, In both techniques (Z-POEM and POES), once the cricopharyngeal muscle is exposed, myotomy is performed. After completing the myotomy, the mucosotomy site is closed. POES, Peroral endoscopic septotomy; Z-POEM, Zenker’s peroral endoscopic myotomy; vertical dashed line, mucosotomy; horizontal purple dashed line with arrow, submucosal dissection; horizontal red dashed line, myotomy.

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