Endoscopic management of Zenker's diverticulum

Zenker's diverticulum (ZD) is an acquired hypopharyngeal outpouching resulting from upper esophageal sphincter dysfunction. Patients usually present with dysphagia, regurgitation, aspiration, or chronic cough, and the condition predominantly affects elderly individuals. Traditionally, open surgical approaches were considered the standard of care but have been associated with significant morbidity. Over the past two decades, endoscopic techniques have revolutionized the management of ZD. The basic principle of all endoscopic treatment approaches is cricopharyngeal myotomy, which relieves the functional obstruction and consequent dysphagia. Flexible endoscopic septum division (FESD) has emerged as a widely adopted method due to its being minimally invasive, simple, and safe. More recently, third-space endoscopic procedures such as Zenker's per oral endoscopic myotomy (Z-POEM) have expanded the therapeutic armamentarium. In addition, hybrid techniques that combine features of FESD and Z-POEM are being developed to maximize efficacy while minimizing complications. This narrative review will provide an overview of the various endoscopic techniques currently available for the management of ZD.