What is the initial approach to managing a patient diagnosed with Zenker's diverticulum on endoscopy?

Management of Zenker's Diverticulum Discovered on Endoscopy

If a Zenker's diverticulum is discovered incidentally on endoscopy in an asymptomatic patient, no intervention is required; however, if the patient has dysphagia, regurgitation, aspiration, or halitosis, endoscopic cricopharyngeal myotomy should be performed as first-line therapy. 1, 2, 3

Initial Assessment and Decision-Making

When Zenker's diverticulum is identified on endoscopy, the critical first step is determining whether the patient is symptomatic:

• Asymptomatic patients: Observation only, no treatment needed 1, 2
• Symptomatic patients (dysphagia, regurgitation, halitosis, cough, aspiration pneumonia): Proceed with treatment 1, 4

Treatment Approach for Symptomatic Patients

First-Line: Endoscopic Cricopharyngeal Myotomy

Endoscopic techniques have replaced open surgery as first-line therapy due to superior safety profiles, shorter recovery times, and comparable efficacy. 2, 3

The endoscopic approach involves:

• Flexible endoscopic myotomy using needle-knife papillotome or similar instruments to divide the cricopharyngeus muscle and septum between the diverticulum and esophageal lumen 1, 4
• Zenker's peroral endoscopic myotomy (Z-POEM): The most advanced endoscopic technique, creating a submucosal tunnel and precisely dividing the cricopharyngeus muscle, with clinical success rates of 85.5-93% and major complications in only 4.8-5% of cases 2, 3

Procedural Considerations

Upper esophageal sphincter dilatation should be considered for treatment of dysphagia with disordered upper esophageal sphincter opening, post-cricoid web, cricopharyngeal bar with or without the presence of a Zenker's diverticulum. 5

Key technical points include:

• Mean operative time: approximately 28 minutes 4
• Oral intake can typically resume within 24 hours 4
• Hospital stay: 24-48 hours for most patients 4, 6
• Outpatient treatment is often feasible with Z-POEM 2

Alternative Endoscopic Options

• Rigid endoscopic stapling: Achieves symptom relief in approximately 90% of cases but has anatomical limitations that restrict its use in some patients 2, 6
• Laser diverticulostomy: Safe but associated with higher recurrence rates (51% vs 35% for stapling) 6

Expected Outcomes

Endoscopic cricopharyngeal myotomy provides substantial improvement in dysphagia scores and regurgitation symptoms in 7 of 9 patients (78%), with Z-POEM achieving success rates up to 92-93%. 1, 2, 3

Long-term considerations:

• Recurrence rates with Z-POEM: as low as 1.4% at one-year follow-up 2
• Overall clinical recurrence: 35-51% depending on technique used 6
• Re-do procedures may be needed in approximately 11% of patients for persistent dysphagia 4

Complications and Safety

Major complications occur in only 4.8-5% of endoscopic cases, with microperforation being the most common, typically managed conservatively. 2, 4

Specific risks include:

• Microperforation: rare, treated conservatively with antibiotics and observation 4
• Postoperative infection: 3.4-19.6% depending on antibiotic prophylaxis protocols 6
• No procedure-related mortality reported in recent series 6

When to Consider Open Surgery

Open transcervical cricopharyngeal myotomy should be reserved for:

• Patients with unfavorable anatomy for endoscopic approaches 2
• Failed endoscopic treatment (initial endoscopic treatment does not preclude future open repair) 1
• Availability of specialized endoscopic expertise is limited 2

Open surgery achieves long-term symptom resolution in 90-95% of cases but carries higher complication rates (up to 30%) and prolonged recovery times. 2

Critical Pitfalls to Avoid

• Do not perform endoscopy during acute symptoms or while on antisecretory therapy: Endoscopy should be conducted when symptoms are present but after a minimum of one month off antisecretory therapy 5
• Do not use weighted (Maloney) bougies with blind insertion for any dilatation procedures, as safer wire-guided techniques are available 5
• Do not assume all dysphagia is from the diverticulum: The diverticulum may be incidental, and other causes of dysphagia should be excluded 5