Digestive Endoscopy 2018; 30: 449–460
13035
Review
New and emerging techniques for endoscopic treatment
of Zenker’s diverticulum: State-of-the-art review
Sauid Ishaq,1,2,4 Haleema Sultan,1 Keith Siau,1,3
Helmut Neumann7
1
Department of Gastroenterology, Russell Hall Hospital, Dudley, 2Birmingham City University, Birmingham, 3Joint
Advisory Group on Gastrointestinal Endoscopy, Royal College of Physicians, London, UK, 4St George’s University,
Grenada, West Indies, 5Department of Gastroenterology, National Hospital Organization, Kure Medical Center
and Chugoku Cancer Center, Kure, Japan, 6Department of Gastroenterology and Hepatology, VU Medical Center,
Amsterdam, Netherlands and 7Department of Interdisciplinary Endoscopy, University Hospital Mainz, Mainz,
Germany
Zenker’s diverticulum (ZD), or pharyngeal pouch, is an anatom-
ical defect characterized by herniation of the posterior pharyn-
geal wall through Killian’s dehiscence, and may result in
dysphagia and regurgitation. Multiple therapeutic modalities
including surgery, rigid and flexible endoscopy have been
developed to manage ZD. Although surgical management with
open and endoscopically assisted techniques have historically
been the mainstay of ZD treatment, minimally invasive flexible
endoscopic techniques, carried out under conscious sedation,
are increasingly favored. Over the last two decades, the advent
INTRODUCTION
Z ENKER’S DIVERTICULUM (ZD), also known as
pharyngeal pouch, is a condition characterized by
herniation of the posterior pharyngeal wall. Specifically, this
occurs in an area located between the thyropharyngeus and
the cricopharyngeal muscle fibers of the inferior constrictor,
known as Killian’s triangle.1 ZD is a relatively rare disorder
with a prevalence ranging between 0.01% and 0.11%.2
There is a male preponderance and it is most common in the
7th–8th decades of life.3 Clinically, ZD may manifest with
symptoms such as dysphagia, regurgitation, and its associ-
ated complications.
Historically, ZD was first described in 1769 by Ludlow,4
an English surgeon, as an autopsy finding. In 1877, Zenker
described an esophageal diverticulum occurring as a result
of ‘forces with the lumen acting against restriction’ and the
condition has since been eponymized.5 In 1886, Wheeler
Corresponding: Sauid Ishaq, Department of Gastroenterology,
Russell Hall Hospital, Esk House, Dudley DY12HQ, UK. Email:
sauid.ishaq@dgh.nhs.uk
The authors Sauid Ishaq and Haleema Sultan are co-first
authors.
Received 16 October 2017; accepted 4 February 2018.
© 2018 Japan Gastroenterological Endoscopy Society
doi: 10.1111/den.
Toshio Kuwai,5 Chris J Mulder6 and
of new accessories and techniques have changed the landscape
of endotherapy for ZD, with the current armamentarium
including, but not limited to, endoscopic stapling, CO2 laser,
argon plasma coagulation, needle knife, bipolar forceps, hook
knife, clutch cutter, stag beetle knife, and submucosal tunneling
endoscopic septum division. We hereby review the latest
evidence to support the endoscopic management of ZD.
Key words: dysphagia, pharyngeal pouch, Zenker’s
diverticulum
carried out the first surgical excision of ZD.6 Endoscopic
treatment for ZD was introduced by Mosher in 19177 who
excised the diverticular septum using a rigid endoscope.
This was modified by Dohlman and Mattsson in 1960 who
incorporated the use of diathermy.8 In 1993, the technique
further evolved to include endoscopic stapling after septal
division.9 As ZD commonly affects the elderly, there has
been increasing demand for minimally invasive methods for
the population who may otherwise have been unsuitable for
general anesthesia. The first use of minimally invasive
flexible endoscopic therapy in ZD was reported in 1995 by
Mulder and Ishioka.10,11 Ever since, endoscopic techniques
have been adapted over the last two decades with increasing
operative success and safety profile, and are beginning to
replace conventional surgery as the mainstay of treatment
for ZD.
The present review aims to provide a synopsis of the
established and emerging therapeutic methods for ZD, with
particular focus on the latest evidence.
Anatomy and pathophysiology
The pharynx comprises two groups of pharyngeal degluti-
tion muscles. The longitudinal group elevates and shortens
449
450 S. Ishaq et al.
the pharynx. The circular muscles include the superior,
middle and inferior constrictors, which serve to clear the
trailing portion of bolus into the esophagus.12 The inferior
pharyngeal constrictor is formed from the thyropharyngeus
and the cricopharyngeus (CP). The CP muscle wraps
posteriorly around the cricoid cartilage and has superior
and inferior components. ZD forms in the area between the
two components of the CP muscle. Manometric studies
support the hypothesis that ZD arises as a result of increased
intraluminal pressure in the esophagus in conjunction with
impaired relaxation of the upper esophageal sphincter
(UOS),12,13 whereby the maximal pressure coincides with
the location of ZD. Studies have suggested that acid reflux
can indirectly predispose to ZD by increasing UOS
pressure.14,15 Moreover, the development of ZD may also
be preceded by the radiological finding of a cricopharyngeal
bar, characterized by hypertrophy and fibrosis of the CP
muscle, which is also associated with older age and
neuromuscular disorders.16
Assessment of Zenker’s diverticulum
Dysphagia is the predominant symptom in ZD. Several
assessment tools have been validated to quantify dysphagia
severity. These include the Dakkak and Bennett scale,17
EAT-10,18 MDADI,19 and SWAL-QOL.20 SWAL-QOL is a
44-item scale which measures dysphagia-related quality of
life, and has been used to measure response to treatment
after endoscopic therapy.21 However, regurgitation and
aspiration are commonly associated with ZD, but may be
underrepresented by these dysphagia-specific scoring scales.
There is thus a need for a novel symptom assessment tool
specific for ZD, which may be better suited for assessing
response to treatment.
Fluoroscopic assessment (e.g. contrast swallow) remains
the gold standard modality for diagnosing ZD (Fig. 1).22
Although diagnosis may be made by endoscopy and cross-
sectional imaging, fluoroscopy allows for dynamic visual-
ization at various stages of deglutition, with the additional
advantage of enabling assessment of diverticular sac
dimensions.
ESTABLISHED TREATMENTS
T REATMENT FOR ZD should be limited to symp-
tomatic patients. The aims of ZD management are to
provide symptomatic relief and improve quality of life. The
endpoint of therapy is to dissect the septum of the
cricopharyngeal muscle (i.e. myotomy) in order to create a
common cavity between the diverticulum and esophageal
lumen.
© 2018 Japan Gastroenterological Endoscopy Society
Digestive Endoscopy 2018; 30: 449–460
Currently, there are three main treatment options for ZD:
open surgery (i.e. transcervical diverticulectomy, diverticu-
loplexy with myotomy of the cricopharyngeal muscle, or
diverticular inversion), rigid endoscopy (i.e. endoscopic
stapling or CO2 laser treatment) and flexible endoscopy.
Although therapy should be considered for all symptomatic
patients, contraindications for each procedure should be
considered and these are summarized in Table 1. Success
rates of therapy appear comparable between modalities
(surgery: 80–100%, rigid endoscopy: 90–100%, flexible
endoscopy: 43–100%), but symptomatic recurrence can be
as high as 19% for surgery,24,25 12.8% for rigid endoscopy
and 20% for flexible endoscopy.26 Surgery is associated
with significant morbidity and mortality, with rates of 30%
(vs 3% for rigid endoscopy and 1.5% for flexible
endoscopy) and 3%, respectively.27,28 Approaches using
rigid endoscopy have limitations, including the need for
general anesthesia and high rates of intraoperative aban-
donment (7.7%), mainly in cases of small diverticular size
(<3 cm) and restricted neck mobility (Table 1).25 Although
the open approach may be feasible for smaller pouch sizes,25
it is an invasive procedure which merits careful patient
selection.29 The limitations of surgery and rigid endoscopy
have therefore led to a demand for a flexible endoscopic
approach to manage ZD.30
Flexible endoscopic septum division
Flexible endoscopic septum division (FESD) involves the
use of a flexible endoscope to carry out septal myotomy. The
goal of treatment is to reduce the size of the diverticulum
and improve pharyngeal motor function, thus improving the
symptoms of dysphagia and regurgitation.
The technique is often used in conjunction with several
pre-endoscopic measures. A transparent cap (Fig. 2a) may
be attached to the end of the endoscope to improve
operating space, and may also aid cases of difficult
intubation arising from ZD. The technique is often used in
conjunction with a diverticuloscope, a specific overtube
designed to straddle the CP between two flaps (Fig. 2b).
Nasogastric tube placement (Fig. 2c) is favored by some
endoscopists to delineate the esophagus, and allows for
enteral feeding in the event of perforation.
Safety and efficacy of FESD has been confirmed in a
meta-analysis by Ishaq et al.31 with a pooled success rate of
91%, adverse event rate of 11.3%, and recurrence rate of
10.5%. A summary of FESD treatment success and
recurrence rates, based on varying follow-up durations, are
provided in Table 2. In a meta-analysis of 596 patients
comparing endoscopic and surgical approaches, Albers
et al.51 reported improved symptom reduction (standardized
Digestive Endoscopy 2018; 30: 449–460
Radiografia com Bário ainda é o padrão ouro para o diagnóstico do Divertículo de Zenker.
(a)
Figure 1 (a) Barium swallow showing contrast within a Zenker’s diverticulum measuring 8 cm in diameter. (b) Anteroposterior
views of residual diverticulum after endoscopic treatment.
mean difference [SMD] 0.08, 95% CI 0.03–1.13) with
surgery, but increased rates of complications (SMD 0.09,
95% CI 0.03–0.43). Notably, differences in diverticular size
between groups were not subjected to heterogeneity assess-
ment.
Complications of FESD mainly include cervical emphy-
sema (5.7%), perforation (4.0%) and bleeding (3.1%).27
Perforation and hemorrhage are typically amenable to
endotherapy. These are outweighed by the advantages of
FESD which precludes the need for general anesthesia
and cervical hyperextension, conferring clear benefits to
the elderly population base. Other advantages include
shorter procedural duration, lower complication rates,
shorter inpatient stay,52 and reduced fasting period.51
The appeal of flexible endoscopic management has
brought forth the evolution of new incision techniques
and devices, with the aim of safe and efficient CP
myotomy.
EVOLUTION OF DEVICES
T HE FIRST CUTTING device used in FESD in 1995
was the needle knife papillotome (Wilson Cook,
Bloomington, IN, USA) which applied diathermy to dissect
the septum (Fig. 3a).11 Advantages of the needle knife
include low cost, easy availability, but disadvantages
include difficulty in precise knife tip control, and the
procedure involving a downward cutting motion of the
septum.52 Further, the monopolar energy may lead to muscle
contractions and tension, hindering precise myotomy. This
Endotherapy for Zenker’s diverticulum 451
(b)
may risk perforation and mediastinitis, which occurs in up to
23% of cases.30,35
The role of argon plasma coagulation (APC) (Fig. 3b)
and carbon dioxide (CO2) laser are not confined to rigid
endoscopy and may be used for FESD. The CO2 laser has
advantages such as low cost and wide availability. However,
disadvantages include relative difficulty in delivering tar-
geted treatment and the potential for thermal injury,52 which
may precipitate surgical emphysema and delayed perfora-
tion.53 Similarly, complications of APC remain high, with
one series reporting complications in 25%, comprising:
fever (17%), hemorrhage (6%) and surgical emphysema
(2%).34
The Harmonic scalpel (Ethicon Endo-Surgery, Cincinnati,
OH, USA) (Fig. 3c) is used in conjunction with a divertic-
uloscope. As another dissecting device, the blades operate
ultrasonically and have the ability to simultaneously cut and
coagulate tissue, causing vessel tamponade.2 Other potential
advantages include better exposure of the septum,54–56
improved procedural accuracy and safety, and wall protec-
tion offered by the diverticuloscope. Success rates from
small series have been reported at 80–100%.55,56 In the
largest cohort studied (N = 25), Fama et al.54 presented one
case of subcutaneous emphysema (4%) and two cases of
chest pain (8%), without hemorrhage or mediastinitis.
However, this technique requires neck extension to position
the diverticuloscope, and is deemed safer under general
anesthesia,52 which limits the pool of suitable patients.
The Hook knife (Olympus Co., Tokyo, Japan) (Fig. 3d) is
another cutting device which was originally designed for
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452 S. Ishaq et al. Digestive Endoscopy 2018; 30: 449–460

Table 1 Contraindications for open surgery, rigid endoscopy design enables CP muscle fibers to be grasped, pulled
and FESD upwards, and then cut, leading to a complete myotomy.
Contraindications Open surgery/Rigid FESD Theoretically, the upwards pull of septal fibers minimizes
endoscopy perforation risk. Repici et al.39 (N = 32) reported a com-
plication rate of 6.3% and overall success rate of 90.6% with
Symptoms Absence of symptoms Hook knife myotomy. Similar findings were presented by
More probable alternative cause of
Rouquette et al. (N = 24), who showed overall success rates
symptoms
of 91.7%, complication rates of 8.4% and recurrence in
Expertise Lack of operator expertise
Absence of anesthetics support 12.5%.50
ZD size Size <3 cm Any size: ideally The Stag Beetle (SB) knife (Sumitomo Bakelite Co.,
>2 cm Tokyo, Japan) (Fig. 3e) is a scissor-shaped cutting tool that
GA Carried out under Can be done under can be used to divide the septum and is often used with a
GA, hence deep sedation. Can diverticuloscope or cap.44 Both blades of the SB knife are
contraindicated in be safely carried out insulated externally. It has two significant advantages over
patients with in those with other cutting devices. First, the SB knife allows the
contraindication to contraindication to incision from the apex to the base of the septum but with a
GA, e.g. frailty, ASA GA. scissor-like movement, which pulls the muscle fibers
III+.23
towards the endoscope while cutting. In addition, the
Cervical-spine Contraindicated in Can be done in
360-degree rotational ability increases therapeutic precision
mobility patients with limited patients with
cervical restricted cervical and prevents unwanted deep incisions that may lead to
hyperextension, e.g. mobility perforation. In a retrospective study of 31 patients
severe cervical undergoing SB knife septal myotomy,44 Battaglia et al.
spondylosis, described a median procedure time of only 14 min, with
atlanto-axial 83.9% of patients in symptom remission after a median
instability follow up of 7 months. Efficacy and safety data were
Patient factors Refusal of consent replicated by Goelder et al.59 (N = 52), who reported a
Uncontrolled coagulopathy low recurrence rate of 9.6% over 6 months, without
Antithrombotic therapy associated with complications of perforation or mediastinitis.
bleeding risk
Severe hypoxemia
Restricted access to ZD
EMERGING DEVICES
ASA, American Society of Anesthesiologists; FESD, flexible endo-
scopic septum division; GA, general anesthestic; ZD, Zenker’s
diverticulum. T HE CLUTCH CUTTER knife (DP2618DT-35; Fuji-
film, Tokyo, Japan) (Fig. 4a) is a novel device with a
rotatable serrated cutting edge measuring 0.4 mm in width
endoscopic submucosal dissection (ESD).57,58 The tip of the and 3.5 mm in length,60 and has an insulated outer coating.
knife is bent at a right angle, with the rotatable ‘hook’ Its rigid blades allow selective grasping and cutting of the
measuring 1.3 mm and the arm measuring 4.5 mm. This CP muscle, increasing its precision.61 However, the efficacy

(a) (b) (c)

Figure 2 (a) Transparent cap; (b) Diverticuloscope (ZDO-22-30; Cook Endoscopy, Winston-Salem, MA, USA); (c) Nasogastric tube
that delineates the diverticular septum from the esophagus.

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Digestive Endoscopy 2018; 30: 449–460 Endotherapy for Zenker’s diverticulum 453

Table 2 Summary of FESD studies that have assessed treatment success and recurrence rates; adapted with permission from Ishaq
et al.31

Study N Treatment Average follow-up Recurrence rate (%)

success rate (%) duration (months)

Ishioka et al. 199511 42 100 38 7.1

Mulder et al. 199510 20 100 6.7 0
Hashiba et al. 199932 47 96 1 day to 1 year 4.2
Evrard et al. 200333 30 96.6 12.5 3.3
Rabenstein et al. 200734 41 95.1 16 12.2
Costamagna et al. 200735 11† 91 6.5 9
Vogelsang et al. 200730 31 84 24 32.3%
Christiaens et al. 200736 21 100 22.6 0
Al-Kadi et al. 201037 18 78 27.5 11.1
Case & Baron 201038 22 100 12.7 31.8
Repici et al. 201039 32 87.5 23.9 6.2
Repici et al. 201140 28 92.9 20 3.6
Huberty et al. 201341 150 94.6 43 23.1
Manno et al. 201442 19 100 27 10.5
Laquie
re et al. 201543 42 88.1 16 14.2
Battaglia et al. 201544 31 90.3 7 6.5
Halland et al. 201645 52 100 26 11.5
Pescarus et al. 201646 26 100 21.8 11.5
Costamagna et al. 201647 89 85.5 36 10.8
Antonello et al. 201648 59 83.1 18 18.6
Go€lder et al. 201749 18 88.9 3 5.6
Rouquette et al. 201750 24 91.7 19.5 12.5
†
Data based on diverticuloscope-assisted cohort.
FESD, flexible endoscopic septum division; N, number of patients.

(a) (b) (c)

(d) (e)

Figure 3 Established devices for septal myotomy. (a) Needle knife Cook Medical, Winston-Salem, NC, USA; (b) argon plasma
coagulation catheter; (c) Harmonic scalpel (Ethicon Endo-Surgery, Cincinnati, OH, USA); (d) Hook knife (Olympus Co., Tokyo,
Japan); (e) Stag Beetle knife (Sumitomo Bakelite Co., Tokyo, Japan).

© 2018 Japan Gastroenterological Endoscopy Society

454 S. Ishaq et al.
Figure 4 Emerging devices for septal myotomy. (a) Clutch Cutter (DP2618DT-35; Fujifilm, Tokyo, Japan); (b) Microcutter
XCHANGE 30 (Cardica Inc., Redwood City, CA, USA); (c) flexible rotatable bipolar forceps (“BELA” prototype instrument; Ethicon,
Endo-Surgery, Cincinnati, OH, USA); (d) Ligasure device (LS1500, Covidien; Medtronic, Minneapolis, MN, USA).
of the Clutch Cutter is currently confined to case
reports.60,61
Modern stapling devices (MicroCutter XCHANGE 30;
Cardica Inc., Redwood City, CA, USA) (Fig. 4b) has been
modified for use with flexible endoscopes.62 This confers
advantages over a rigid endoscope by improving visualiza-
tion and accessory positioning, and enables therapy under
conscious sedation.62 This new device involves a thin 5-mm
surgical stapler which rotates to 80 degrees in each direc-
tion. However, in their series of 17 patients, Wilmsen et al.
reported a success rate of only 64.7%,62 with procedural
failure in patients with insufficient head reclination and
those with thick CP muscle.
Flexible rotatable bipolar forceps (“BELA” prototype
instrument; Ethicon, Endo-Surgery) are currently in devel-
opment and are a novel device for CP myotomy (Fig. 4c).63
A study on porcine models has shown advantages over
needle knife cautery. As a result of its jaw-like shape, the
forceps fix the tissue to prevent unwanted movement, and
allows precise therapy. In one small series (N = 5), precise
dissection of the CP septum was shown in all patients.
Instead of relying on precise endoscope positioning, the
maneuverability of the bipolar forceps allows easier target-
ing of the intended dissection plane.
Recently, the role of Ligasure (LS1500, Covidien;
Medtronic, Minneapolis, MN, USA) has been evaluated for
endoscopic diverticulotomy (Fig. 4d).64 The Ligasure vessel
© 2018 Japan Gastroenterological Endoscopy Society
Digestive Endoscopy 2018; 30: 449–460
sealer is used to dissect the tissue and simultaneously provide
hemostasis at the site. In this small study (N = 8), technical
success rate was 100% on a range of diverticular sizes, with
one case of bleeding reported as the only complication. Thus,
further studies are required to assess its role in ZD.
Novel computer-assisted flexible endoscope systems are
also being developed.65 The Flex System (Medrobotics,
Raynham, MA, USA) (Fig. 5) features a surgeon operated-
controlled unit, touchscreen monitor and a base for the
attachment of the flexible endoscope which can be maneu-
vered with a 3D joystick. This confers advantages including
better visualization and laryngeal access compared to open
surgery, and allows for suturing of the mucosa and closure
of small perforations. A wide range of accessories and
devices are compatible with this system, which may
accommodate patients with restricted neck mobility. Disad-
vantages include the requirement for general anesthesia,
setup costs, and potential learning curve.
INCISION TECHNIQUES
T HE SINGLE-INCISION TECHNIQUE involves a
midline incision to the cricopharyngeal septum with
the option of clipping the base.41 This is usually used with
needle knife, APC and the Hook knife.
The double-incision technique allows a wider area of the
septum to be dissected.66 It involves creating two, 1-cm
Digestive Endoscopy 2018; 30: 449–460 Endotherapy for Zenker’s diverticulum 455

Figure 5 Flex system setup (Medrobotics, Raynham, MA, USA). A joystick is used by the surgeon as a control unit. The
endoscope is driven with computer assistance and has a distal tip diameter of 15 mm 9 17 mm. Flexible instruments are
manipulated independently by the hand of the surgeon. Reproduced with permission from Elsevier.65

incisions, which are made 1 cm apart from each other. The
septum in-between the incisions is then resected using a
snare and the base is clipped.49 One study reported a
complete remission rate in 71.4% after one session, with the
remainder reporting symptom improvement after therapy
was repeated.66
A novel technique involving wedge-shaped volumetric
excision of the septum has also been described which
similarly aims to reduce the recurrence rate of ZD.67 It
involves fixing the cricopharyngeal septum with a suture,
which is then secured with a clamp, followed by dissection
inferomedially on either side of the suture creating a wedge-
shaped incision, allowing a larger section of tissue to be
removed. A snare then resects this incision. Data from a
small series (N = 6) have shown complete resolution, with
no significant complications.67
Submucosal tunneling endoscopic septum division
(STESD) is a technique that has most recently been inspired
by peroral endoscopic myotomy (POEM) (Fig. 6).68–70 This
cutting-edge technique obviates direct dissection of the CP
septum and, instead, involves dissecting a submucosal
tunnel around the septum to achieve a complete myotomy.
This is important as longer septostomy is a prognostic
marker of procedural success.47 Theoretically, STESD is
associated with reduced risk of perforation and mediastinitis
as the esophageal mucosa is sealed with clips, as well as
reduced recurrence rates. Efficacy for STESD is still
confined to case reports.68–70 Its mainstream application is
restricted by lack of evidence, and expertise in POEM.
Endoscopic management of recurrent
Zenker’s diverticulum
Regardless of treatment modality, ZD recurrence is not
uncommon (Table 2). Predictors of symptom relapse within
48 months of endoscopic therapy include pretreatment ZD
size (≥50 mm), post-treatment ZD size (≥10 mm), and
length of septostomy (≤25 mm).47 The effectiveness of redo
myotomy has been shown in recurrent ZD.36,39,41,50 In their
retrospective study (N = 134), Huberty et al.41 reported

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456 S. Ishaq et al. Digestive Endoscopy 2018; 30: 449–460

Figure 6 Submucosal tunneling endoscopic septum division. (a) Zenker’s diverticulum (black arrow). (b) Submucosal injection
and mucosal incision toward the submucosal space. (c) Creation of the submucosal tunnel and clear exposure of the muscle
fibers of the septum inside the tunnel. (d) Septum division started inside the tunnel. (e) Complete myotomy beyond the bottom
of the diverticulum. (f) Closure of mucosal entry. Reproduced with permission from Elsevier.68

recurrence rates of 23.1%; of those who underwent repeat
treatment (N = 23), 78.3% achieved symptom remission
after redo myotomy.
Endoscopic management of recurrence after surgery or
endoscopic stapling can be particularly challenging. Staples
within small residual pouches can result in an adequate grasp
of the common wall between the diverticulum and the
esophagus, and a higher risk of perforation is encountered
when small pouches are stapled.71 Moreover, the staple-over-
staple effect may lead to unpredictable scarring and fibrosis
that can lead to persistent dysphagia despite apparent
procedural success.72 In their series of 25 patients with post-
surgical recurrence, Antonello et al.48 described symptom
remission in 84%, with partial improvement in the remainder.
Thus, flexible endoscopic therapy remains a viable alternative
to surgery even in postoperative recurrences.
Safety
High-flow intranasal devices,73 such as OptiflowTM (Fisher &
Paykel Healthcare Ltd, Auckland, New Zealand), deliver low-
level positive airway pressure with up to 70 L/min oxygen,
and prevent hypoxemia. As endoscopic treatment for ZD is
often a relatively short procedure carried out under conscious
propofol sedation, Optiflow is thought to be an effective
method in stabilizing oxygen saturation, while avoiding the
need for intubation and ventilation.74 Thus, it is particularly
useful in the setting of elderly, higher-risk ZD patients.
The risks associated with general anesthesia, particularly
in the patient base with ZD are well recognized. Deep
sedation with a continuous propofol infusion has been used
in flexible endoscopic procedures,74 and can be used
alongside analgesics such as fentanyl.74 Benefits of propofol
sedation over benzodiazepines include rapid onset of action,
short half-life of 4 min, improved patient cooperation,75 and
favorable safety profile.75,76
DISCUSSION
E STABLISHED AND EMERGING treatment strategies
for ZD are summarized in Figure 7. Flexible endoscopy
is a safe, effective and minimally invasive option for treating

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Digestive Endoscopy 2018; 30: 449–460 Endotherapy for Zenker’s diverticulum 457

ZD. Popularity of FESD has catalyzed the research and
development of available accessories, technologies, and
operative approaches to maximize the safety and efficacy
profile.
Based on meta-analysis data,31 pooled rates of complica-
tions (11.3%) and recurrence (11.0%) remain high. Studies
carried out pre-2005 were associated with increased clinical
success, but with higher recurrence rates.31 This observation
is interesting, particularly when quality of training and
practice has improved considerably over this time. One
possible explanation could be the lack of a single standard-
ized technique. As technology for ZD therapy evolves
without real-world patient volume to develop endoscopist
expertise, the optimal combination of technique and device
to achieve favorable safety, efficacy and long-term outcome
remains unclear.

Figure 7 Summary of current approaches available for Zenker’s diverticulum presented in the present review. POEM, peroral
endoscopic myotomy; STESD, submucosal tunneling endoscopic septum division.

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458 S. Ishaq et al.
As a result of the relative infrequency of the condition,
studies for ZD therapy are, at best, limited to small
prospective studies, without randomized controlled trial
data. There is a clear need for larger, well-designed,
comparative prospective studies to assess the optimum
method and treatment device in order to allowing standard-
ization of training and practice. Additionally, universal
definitions of outcomes, such as treatment success, relapse
and complication rates, are needed to allow better compar-
isons between studies and to quality assure practice. There
may be a role for specialist tertiary units to manage ZD,
where there is sufficient volume to preserve the competence
of endoscopists. There is also a case for multidisciplinary
interaction with otolaryngologists and anesthesiologists to
determine the optimum treatment modality for each affected
patient, and for outcomes in both specialties to be
monitored.
Since the inception of FESD, there has been no consensus
on the training and technical aspects of how therapy should
be carried out. As discussed in this review, the optimal
technique remains controversial; for instance, the impor-
tance of keeping the buccopharyngeal fascia intact during
septum incision, as advocated by Chang et al.77, has seldom
been reported. As a result of ZD being a rare disorder,
training in therapeutic endoscopy can be challenging, with
an unknown learning curve. There is a clear need to ensure
that training for such a high-risk procedure is of sufficient
quality, and that necessary technical and non-technical
competencies have been attained before allowing unsuper-
vised practice. For this, a standardized framework for
defining competence in FESD is required, supported by
mentorship and methods of competence assessments.
Beginners in FESD may benefit from training outside the
endoscopy room. Emphasis should begin with anatomical
considerations, including the buccopharyngeal fascia and
the pharyngeal deglutition muscles, in addition to the CP. As
most domestic pigs possess pharyngeal diverticulae resem-
bling human ZD,78 porcine models may be a useful tool in
training and assessment. Also in development is a surgical
simulator which demonstrates content and construct validity
in allowing trainees to acquire skills within a controlled
environment to develop competence in ZD therapy.79
Currently, there is a notable lack of clinical guidelines or
auditable performance metrics in the endoscopic manage-
ment of ZD. Establishing these are fundamental to the
process of quality assurance, which has seen significant
strides in the quality and outcomes of diagnostic and
therapeutic endoscopic modalities in the last two decades.
Incorporating quality assurance into the ZD arena may be
the upcoming strategy to improve operator proficiency and
patient outcomes in the future.
© 2018 Japan Gastroenterological Endoscopy Society
Digestive Endoscopy 2018; 30: 449–460
CONFLICTS OF INTEREST
A UTHORS DECLARE NO conflicts of interest for this
article.
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