Endoscopic management of Zenker’s diverticulum: stapling vs. Z-POEM

Zenker’s diverticulum (ZD) is a rare disease of the elderly. Surgery was the first treatment option for many years. Subsequently many different endoscopic treatments have been introduced in order to reduce the complication rate. Endoscopic stapled diverticulostomy (ESD) is a well-known procedure since 1993. Recently an endoscopic myotomy of the upper esophageal sphincter (UES), called per-oral-endoscopic-myotomy for Zenker’s diverticulum (Z-POEM) and derived from the POEM technique for achalasia, has been proposed. The aim of this study is to describe and compare these two different techniques for treatment of ZD in order to assess their efficacy and safety. We reviewed literature of the last 10 years on 1,490 patients that underwent ESD from 11 different papers and on 96 patients from 9 papers that underwent Z-POEM. Surgical procedure techniques, clinical and technical success, recurrence rate and complications were reviewed. The most common complications are bleeding and perforations that most of time are self-resolving but sometimes could require a surgical intervention. Other minor but frequent complications are dental avulsions and lips tears. Only one death was described among those submitted to ESD. Both procedures are effective in symptoms solutions with a low recurrence rate. Anyway, the main drawback of ESD is the difficult positioning of the diverticuloscope, that is the main reason for technical failure. On the opposite data about Z-POEM are few and of low quality, so some concerns remain about symptoms such regurgitation and aspiration. Minimally invasive treatment of ZD with both ESD and Z-POEM is a valuable option for this disorder. They are both safe, feasible and effective, in terms of hospital stay, complication rate and clinical success rate. Long-term results have to be evaluated considering a larger population for the Z-POEM procedure.