New and emerging techniques for endoscopic treatment of Zenker's diverticulum: State‐of‐the‐art review

Abstract

Zenker's diverticulum (ZD), or pharyngeal pouch, is an anatomical defect characterized by herniation of the posterior pharyngeal wall through Killian's dehiscence, and may result in dysphagia and regurgitation. Multiple therapeutic modalities including surgery, rigid and flexible endoscopy have been developed to manage ZD. Although surgical management with open and endoscopically assisted techniques have historically been the mainstay of ZD treatment, minimally invasive flexible endoscopic techniques, carried out under conscious sedation, are increasingly favored. Over the last two decades, the advent of new accessories and techniques have changed the landscape of endotherapy for ZD, with the current armamentarium including, but not limited to, endoscopic stapling, CO laser, argon plasma coagulation, needle knife, bipolar forceps, hook knife, clutch cutter, stag beetle knife, and submucosal tunneling endoscopic septum division. We hereby review the latest evidence to support the endoscopic management of ZD.

Impact of prior treatment on feasibility and outcomes of Zenker’s peroral endoscopic myotomy (Z-POEM)

“…1 Calculated on 30 technically successful procedures. 2 Data were available for 24 patients. 3 Data were available for 29 patients.…”

“…Zenker's diverticulum (ZD) is a herniation of mucosa and submucosa through Killian's triangle, a pharyngeal weak point between the lower inferior constrictor muscle and the cricopharyngeal muscle (CPM) [1]. Zenker's diverticulum is essentially treated by complete dissection of the CPM during either open surgery (transcervical approach), rigid endoscopy (stapled or CO 2 laser-mediated), or flexible endoscopy [2]. An endoscopic approach is generally favored owing to the less invasive nature of the therapy, accompanied by a decreased risk of adverse events, and shorter procedure duration and length of hospital stay [3].…”

Evolving flexible endoscopic treatment of Zenker’s diverticulum

“…Open surgery has become exceedingly rare, being replaced by minimally invasive endoscopic techniques such as stapling, laser and argon plasma coagulation, needle and hook knife, bipolar forceps, and submucosal septum division, among others. 7 A new alternative, aiming at a more efficient myotomy on the cricopharyngeal muscle, and thus alleviation of persistent symptoms, is outlined in the current issue of Gastrointestinal Endoscopy by Pang et al 8 In their protocol, a wedge-shaped resection of the cricopharyngeal muscle is advocated. Such a myectomy would prevent tissue regrowth and would create a wider communication between the diverticulum and the esophageal lumen, thus reducing the chance of unremitting or recurrent dysphagia.…”

First two cases of Zenker's diverticulum treated with flexible endoscopic septum division in Japan

“…Flexible endoscopic septum division (FESD) is emerging as an effective minimally invasive treatment for Zenker's diverticulum (ZD) . Overall prevalence of ZD is rare .…”

“…is emerging as an effective minimally invasive treatment for Zenker's diverticulum (ZD). 1,2 Overall prevalence of ZD is rare. 3 Therefore, ZD was historically treated by surgery, 4 and, to date, there are no reports of FESD for ZD in Japan.…”