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Peroral endoscopic myotomy versus flexible endoscopic septotomy for Zenker's diverticulum: a cost-effectiveness
Sneh Sonaiya1, Raj Patel2, Faizan Sheraz3
1Department of Internal Medicine, University of Nevada Las Vegas, Las Vegas, Nevada, USA.
Background And Aims:
Zenker's diverticulum (ZD) is increasingly managed with endoscopic approaches, including flexible endoscopic septotomy (FES) and Zenker's peroral endoscopic myotomy (Z-POEM). Although Z-POEM offers durable symptom relief, its higher procedural costs raise uncertainty regarding its economic value. In this study, we performed a cost-effectiveness analysis comparing Z-POEM with FES for the treatment of ZD.
Methods:
We developed a decision tree model comparing Z-POEM versus FES over a 12- and 24-month time horizon. Model inputs for clinical success, recurrence, adverse events, and procedure costs were derived from published literature and reimbursement estimates. Quality-adjusted life-years (QALYs) were estimated using Gastroesophageal Reflux Disease-Health-Related Quality of Life-derived utility values. A willingness-to-pay (WTP) threshold of $100,000/QALY was applied.
Results:
In the base-case analysis of a 70-year-old patient with ZD over a 12-month time horizon, Z-POEM was associated with higher costs and modest incremental effectiveness compared with FES (incremental cost, $5706; incremental effectiveness, 0.01461 QALYs), resulting in an incremental cost-effectiveness ratio of $390,344/QALY, exceeding conventional WTP thresholds. Sensitivity analyses demonstrated that results were most influenced by procedural costs and clinical success probabilities. Probabilistic sensitivity analysis showed that in the short term, FES remained more likely to be cost-effective at standard WTP thresholds. However, in the 24-month analysis incorporating long-term recurrence, Z-POEM became cost-effective compared with FES, driven by improved durability and reduced need for reintervention.
Conclusions:
Over a 12-month time horizon, FES appears to be the economically preferred strategy for the treatment of ZD. Although Z-POEM is clinically effective, its higher upfront costs limit short-term economic value. However, when longer-term outcomes are incorporated, Z-POEM may become cost-effective over a 24-month horizon, driven by improved durability and lower recurrence compared with FES.
