Traction on the septum during transoral septotomy for Zenker diverticulum improves the final outcome

Transoral septotomy versus Z-POEM in the treatment of Zenker diverticulum: a multicenter case-matched comparative study

INTRODUCTION

Transoral septotomy has become the favored treatment of Zenker Diverticulum (ZD), with POEM becoming a mini-invasive option also in ZD. The gold-standard treatment of ZD is still debated. We designed a case-matched comparative study to evaluate whether POEM (Z-POEM) could be as effective as stapler, traction-assisted Transoral Septotomy (TS) as first-line treatment of ZD.

MATERIALS AND METHODS

Consecutive naïve patients between 2015 and 2022 were enrolled in two high-volume centers. Barium-swallow and endoscopy were performed before and after surgery. Symptoms were assessed using a dedicated questionnaire. A control group was generated by matching patients who underwent Z-POEM with those who underwent TS. For matching the patients, a one-to-one nearest neighbor approach was used. Patients were matched for: septum length, symptoms duration, age, and sex.

RESULTS

After matching, 26 patients in each group were enrolled. The procedures were completed successfully in all patients in both groups, and mortality was null. TS required a shorter operative time. One leakage was detected in the Z-POEM group while one mucosal tear was detected in the TS group, both treated conservatively. At a median follow-up of 45 months (IQR: 27-68) for TS and 66 months (IQR: 58-76) for Z-POEM, a successful outcome was achieved in 96.2% in both groups. Post-operative symptom scores decreased in all patients in both groups.

CONCLUSIONS

This is the first study comparing Z-POEM and TS. Both the minimally invasive treatments are effective for naïve Zenker Diverticulum. TS provides a lower rate of intraoperative complications and a shorter operative time.

Transoral septotomy with septum traction is an effective treatment for recurrent Zenker diverticulum

Symptoms of Zenker diverticulum can recur whatever the type of primary treatment administered. A modified transoral stapler-assisted septotomy (TS) was introduced in clinical practice a few years ago to improve the results of this mini-invasive technique. The aim of this prospective, controlled study was to assess the outcome of TS in patients with recurrent Zenker diverticulum (RZD), as compared with patients with treatment-naïve Zenker diverticulum (NZD). Patients diagnosed with NZD or RZD, and treated with TS between 2015 and 2021 were compared. Symptoms were recorded and scored using a detailed questionnaire. Barium swallow and endoscopy were performed before and after the TS procedure. In sum, 89 patients were enrolled during the study period: 68 had NZD and 21 had RZD. The patients' demographic and clinical data were similar in the two groups. Three mucosal lesions were detected intra-operatively, and one came to light at post-operative radiological assessment in the NZD group. No mucosal lesions were detected in the RZD group. The median follow-up was 36 months (interquartile range 23-60). The treatment was successful in 97% NZD patients and 95% of RZD patients (P = 0.56). This is the first comparative study based on prospectively collected data to assess the outcome of TS in patients with RZD. Traction on the septum during the procedure proved effective in the treatment of RZD, achieving a success rate that was excellent, and comparable with the outcome in treating NZD.

Transoral endoscopic repair of Zenker diverticulum by a thoracic surgical service

OBJECTIVE

Zenker diverticulum (ZD), a pulsion diverticulum of the esophagus, has been traditionally managed with an open surgical approach, but endoscopic transoral stapling has been reported with increasing frequency. The objective of this study was to evaluate the results of endoscopic repair of ZD by a thoracic surgery service.

METHODS

We conducted a retrospective review of patients who underwent transoral stapling repair of ZD at our institution by the thoracic surgery service. We evaluated perioperative outcomes including dysphagia (1, no dysphagia to 5, unable to swallow saliva) and failure of repair requiring surgical intervention.

RESULTS

A total of 151 patients (median age, 78 years; 75 men, 76 women) underwent evaluation for endoscopic repair of ZD. Endoscopic stapled repair of the ZD was completed in 135. Sixteen patients underwent conversion to open repair. The perioperative mortality was 0.6% (1 patient). The median hospital stay was 2 days (range, 0-18 days). Complications occurred in 5 patients who underwent endoscopic repair. The mean preoperative dysphagia score was 2.8 and improved to 1.2 during follow-up (median, 16 months; P < .001). During further follow-up (median, 52 months), 8 patients (5.3%) had failure of the endoscopic repair requiring open surgery (n = 5) or redo transoral stapling (n = 3).

CONCLUSIONS

Endoscopic stapling repair of ZD can be performed safely with good results in experienced centers by thoracic surgeons with significant esophageal experience. Long-term follow-up is required to evaluate the durability of endoscopic repair of ZD.