What are the treatment options for Zenker diverticula?

Treatment Options for Zenker Diverticulum

Endoscopic approaches, particularly Zenker's peroral endoscopic myotomy (Z-POEM), have become the first-line therapy for symptomatic Zenker diverticulum, replacing traditional open surgery due to superior safety profiles, faster recovery, and comparable long-term efficacy. 1, 2

When Treatment is Indicated

Treatment is recommended only for symptomatic patients experiencing dysphagia, regurgitation, aspiration, or malnutrition—asymptomatic small diverticula do not require intervention. 3, 4, 5 The cornerstone of any effective treatment must include cricopharyngeal myotomy to address the underlying pathophysiology of poor upper esophageal sphincter compliance and increased hypopharyngeal pressures. 3, 4

Primary Treatment Algorithm

First-Line: Zenker's Peroral Endoscopic Myotomy (Z-POEM)

Z-POEM should be the preferred initial approach for most symptomatic patients, particularly elderly or high-risk individuals. 1, 2

• Clinical success rates of 85.5-93% with symptom resolution, comparable to open surgery but with significantly fewer complications. 2
• Major complication rates of only 4.8-5%, substantially lower than open surgery's 30% complication rate. 2
• Recurrence rates as low as 1.4% at one-year follow-up in patients with larger diverticula. 2
• Enables outpatient treatment or brief hospital stays (1-2 days) versus prolonged hospitalization with open surgery. 2
• Particularly advantageous for frail elderly patients who comprise the majority of Zenker diverticulum cases. 3, 2

The technique involves creating a submucosal tunnel and precisely dividing the cricopharyngeus muscle, adapted from achalasia treatment protocols. 2 While it requires specialized endoscopic expertise, Z-POEM has demonstrated technical feasibility with low clinical recurrence and adverse event rates. 1

Alternative Endoscopic Option: Rigid Endoscopic Stapling

Rigid endoscopic stapled diverticulotomy remains a viable alternative when Z-POEM expertise is unavailable or for patients with favorable anatomy. 3, 2

• Symptom relief in approximately 90% of cases with lower morbidity than open surgery. 2
• Hospital stays of 1-2 days with faster recovery than open approaches. 2
• Critical limitation: Anatomical constraints restrict its use—patients must have adequate diverticulum size and neck anatomy for stapler placement. 3, 2
• Generally preferred over flexible endoscopy when rigid endoscopic expertise is available. 3

Flexible Endoscopic Myotomy

Consider flexible endoscopic cricopharyngeal myotomy specifically for high-risk patients who cannot tolerate rigid endoscopy or open surgery. 3, 5 This represents a valuable option when other approaches are contraindicated, though it is less commonly performed than Z-POEM or rigid stapling. 3

When to Consider Open Surgery

Open surgical diverticulectomy with cricopharyngeal myotomy should be reserved for specific scenarios where endoscopic approaches have failed or are contraindicated. 3, 4, 2

• Achieves long-term symptom resolution rates of 90-95%. 2
• Major drawback: Complication rates up to 30%, including infections, nerve damage (recurrent laryngeal nerve injury), and prolonged hospitalization. 2
• Longer recovery times compared to all endoscopic approaches. 1, 2
• Consider when: endoscopic treatment has failed, anatomical factors preclude endoscopic access, or in younger patients where long-term durability is paramount. 3, 2

Treatment Selection Based on Diverticulum Size

Upper esophageal sphincter dilatation may be considered for symptomatic cricopharyngeal bar with or without small Zenker diverticulum, particularly when dysphagia is the primary symptom. 6 However, this addresses symptoms rather than definitively treating the diverticulum itself.

For small asymptomatic diverticula, observation without intervention is appropriate as symptoms may never develop. 4

Critical Pitfalls to Avoid

• Never attempt endoscopic treatment without ensuring cricopharyngeal myotomy is performed—failure to address the sphincter dysfunction will result in treatment failure and recurrence. 3, 4
• Do not assume all elderly patients require open surgery; endoscopic approaches are specifically advantageous for this population. 3, 2
• Avoid rigid endoscopic stapling in patients with unfavorable anatomy (small diverticulum, narrow neck)—this leads to technical failure and complications. 3, 2
• Do not delay treatment in symptomatic patients experiencing aspiration or significant malnutrition, as these complications significantly impact morbidity and mortality. 5

Emerging Evidence and Future Directions

While Z-POEM demonstrates excellent short-term outcomes, long-term comparative data beyond one year are still emerging. 1, 2 Current evidence from meta-analyses and multicenter studies supports Z-POEM's comparable success to open surgery with increased patient tolerance, but prospective randomized trials with extended follow-up are needed. 1, 2 The choice between techniques ultimately depends on local expertise, though the trend strongly favors endoscopic approaches in specialized centers. 3, 2