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Review
. 2021;34(2):149-154.
doi: 10.20524/aog.2021.0575. Epub 2021 Jan 16.

Flexible endoscopic treatment for Zenker's diverticulum: from the lumen to the third space

Roberta Maselli  1 , Marco Spadaccini  1   2 , Annalisa Cappello  2 , Edoardo Vespa  1   2 , Milena Di Leo  1 , Alessandro Fugazza  1 , Gaia Pellegatta  1 , Piera Alessia Galtieri  1 , Elisa Chiara Ferrara  1 , Andrea Anderloni  1 , Silvia Carrara  1 , Viveksandeep Thoguluva Chandrasekar  3 , Paul J Belletrutti  4 , Alessandro Repici  1   2
Affiliations
Review

Flexible endoscopic treatment for Zenker's diverticulum: from the lumen to the third space

Roberta Maselli et al. Ann Gastroenterol. 2021.

Abstract

Zenker's diverticulum (ZD) is a rare outpouching of the esophageal mucosa herniating posteriorly through Killian's triangle. Treatments of ZD aim to dissect the cricopharyngeal muscle to remove the underlying dysfunctional condition. In the last decade, a septotomy performed utilizing a flexible endoscope has been reported as a safe and effective alternative to both open surgery and rigid endoscopic diverticulotomy. More recently, Li et al described a novel endoscopic technique to treat ZD, named "submucosal tunneling endoscopic septum division", inspired by the peroral endoscopic myotomy (POEM) procedure developed for achalasia. Subsequently, the term Z-POEM was introduced and has become the most frequently used acronym to define the tunneling technique for ZD. This article describes the flexible therapeutic endoscopic strategies for treating ZD, including the novel third space approach, which seems to show promising potential in terms of clinical efficacy and safety.

Keywords: Endoscopy; Zenker’s diverticulum; esophagus; peroral endoscopic myotomy; third space.

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Conflict of interest statement

Conflict of Interest: None

Figures

Figure 1
Figure 1
Flexible endoscopy options: (A) Flexible endoscopic septum division, (B) Zenker peroral endoscopic myotomy (Z-POEM), (C) Peroral endoscopic septotomy (POES) *Submucosal access in Z-POEM is located proximally to the septum, in the hypopharynx. **Submucosal access in POES is located at the top of the septum
Figure 2
Figure 2
Endoscopic view after complete septotomy by flexible endoscopic septum division approach
Figure 3
Figure 3
Endoscopic view after complete myotomy by Zenker peroral endoscopic myotomy (Z-POEM) approach (intra-tunnel view)
Figure 4
Figure 4
Mucosal incision at the top of the septum for third-space access during peroral endoscopic septotomy (POES) approach
Figure 5
Figure 5
How to deal with different flexible endoscopy options *According to ESGE guidelines, flexible endoscopy should be considered as the first option for symptomatic patients with Zenker’s diverticulum (ZD). Surgical and rigid endoscopy treatment may be viable alternatives. **Data on recurrent ZD are still scanty for third-space approaches. In the future this could change. ***For large ZD a third space approach might leave a significant mucosal flap. We still do not know the clinical consequence of such mucosal excess, however a reliable and well-known procedure such as flexible endoscopic septum division (FESD) may be preferre
See this image and copyright information in PMC

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