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

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.

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.

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.

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.