Zenker's Diverticulum Management
For patients with Zenker's diverticulum presenting with dysphagia, Z-POEM (Zenker's peroral endoscopic myotomy) should be the preferred treatment approach, offering 96-100% clinical success rates with same-day discharge in most cases and minimal complications. 1, 2
Treatment Approach
First-Line Intervention: Z-POEM
Z-POEM represents the optimal therapeutic modality for Zenker's diverticulum, demonstrating superior outcomes compared to traditional approaches:
- Technical success achieved in 100% of patients across multiple international centers 1, 2
- Clinical success (improvement in dysphagia score to ≤1) achieved in 96-100% of patients 1, 2
- Mean procedure time of 48-61 minutes, significantly shorter than surgical alternatives 1, 2
- Same-day discharge feasible in approximately 68% of patients, with median hospital stay of 1 day 1, 2
Key Technical Advantages
The Z-POEM technique utilizes the submucosal third space to create a tunnel, allowing complete visualization and division of the cricopharyngeal septum 2. This overcomes the primary limitation of conventional endoscopic septotomy, which carries higher recurrence risk due to incomplete septum visualization 2.
The procedure can be performed without general anesthesia in an outpatient setting, making it particularly suitable for elderly patients with multiple comorbidities who comprise the typical Zenker's patient population (mean age 74 years) 1, 2, 3.
Patient Selection Criteria
Z-POEM is appropriate for:
- Patients with symptomatic Zenker's diverticulum of any size (successful treatment reported for diverticula ranging 2-7 cm) 2
- Elderly patients with significant comorbidities (58% of patients in recent series had ASA grade 3) 1
- Patients unsuitable for rigid endoscopy due to body habitus or cervical spine limitations 3
Expected Outcomes
Symptom Resolution
- Dysphagia scores improve from mean 1.5 pre-procedure to 0.09 post-procedure (p < 0.001) 1
- Regurgitation scores improve from mean 2.3 to 0.13 (p < 0.001) 1
- Clinical success maintained in 95.8% of patients at median 10-month follow-up 2
Reintervention Rates
Approximately 1 in 5 patients (18.8%) require reintervention during short-term follow-up, with most reinterventions (80%) needed after 17 months from initial Z-POEM 1. This should be discussed during informed consent as a material risk that may influence patient decision-making 4.
Safety Profile
Adverse events are rare with Z-POEM, with reported complications limited to isolated cases of post-procedural atrial fibrillation 1. No perforations, mediastinitis, or procedure-related deaths have been reported in recent large series 1, 2.
Informed Consent Requirements
Essential Information to Provide
Patients must receive information about expected benefits, potential burdens and risks, and alternatives in a format they can understand 4. For Z-POEM specifically, this includes:
- Expected benefit: 96% likelihood of symptom resolution 1
- Procedure duration: approximately 50-60 minutes 1, 2
- Hospital stay: likely same-day discharge or 1-day admission 1, 2
- Reintervention risk: approximately 19% within 2 years 1
- Rare complications: cardiac arrhythmias, though perforation risk is minimal 1
Written information should be provided in advance with sufficient time for the patient to read, evaluate, and seek further information 4. For outpatient procedures, verbal and/or written information should be provided by the recommending clinician at consultation and documented in clinical notes 4.
Communication with Anesthesia
If sedation or anesthesia is planned, communicate the patient's dysphagia severity and diverticulum size to the anesthesiologist prior to procedure 4. Patients with significant dysphagia may have retained food/secretions in the diverticulum, increasing aspiration risk during induction 4.
Procedural Considerations
Sedation Approach
Offer patients intravenous sedation with benzodiazepine and opioid analgesic as minimum, with propofol sedation or general anesthesia as alternatives based on patient preference, procedure complexity, and local expertise 4.
Post-Procedure Monitoring
Monitor patients for at least 2 hours in recovery and provide clear written instructions regarding fluids, diet, and medications 4. Ensure patients tolerate water before discharge 4.
Provide contact information for the on-call team should patients experience chest pain, breathlessness, or become unwell after discharge 4.
Warning Signs Requiring Evaluation
Suspect perforation if patients develop persistent pain, breathlessness, fever, or tachycardia 4. While transient chest pain is common following dilatation procedures, persistent pain should prompt CT scan with oral contrast 4.
Alternative Approaches
For patients who decline Z-POEM or in centers without Z-POEM expertise, flexible endoscopic septotomy using various cutting devices represents an acceptable alternative, with clinical symptom resolution demonstrated in over 600 published cases and low adverse event rates 3. However, this approach has higher recurrence rates due to incomplete septum visualization compared to Z-POEM 2.