Zenker per-oral endoscopic myotomy (Z-POEM): The ideal first-line therapy for treatment of Zenker diverticulum.

Objective: Zenker diverticulum is a mucosal herniation at the pharyngoesophageal junction. Although open surgical myotomy is the conventional treatment, robust evidence on third-space flexible endoscopic myotomy is lacking. We assessed safety, effectiveness, and patient-reported outcomes of per-oral endoscopic myotomy (Z-POEM) in the largest reported single-center experience with this technique.

Methods: A retrospective cohort study was performed of consecutive patients undergoing Z-POEM in a tertiary hospital thoracic surgery practice from 2018 to 2024. Data collected included demographics, comorbidities, clinical and radiographic (pre/postoperative esophagram) outcomes, and validated patient-reported quality-of-life outcomes (Dakkak and Eckardt scores). Descriptive analyses were used to describe the population, outcomes, and complications. Aggregate and individual-patient symptom trajectories were charted over time.

Results: Fifty-seven patients (57.9% female, n = 33) with a mean age of 74 years underwent Z-POEM. Median diverticulum size was 2 cm (interquartile range, 2-3). All patients reported subjective symptom improvement and showed complete resolution of obstructed barium flow on postoperative esophagrams. At median follow-up of 9 months, all patients who underwent Z-POEM reported clinically important improvements in objective symptom scores, with symptom trajectories showing rapid and durable improvement up to 5 years postoperatively. Four patients (7%) experienced complications. The majority of the cohort (66.7%) was unsuitable for rigid stapled myotomy, mainly as the result of short diverticulum or limited neck/mouth movement. No patients required repeat myotomy.

Conclusions: We demonstrate significant and sustained relief of patient-reported outcomes/symptoms after Z-POEM, including for small diverticuli, with low complication rates. Its safety and versatility has made it the new standard of care locally; Z-POEM can be adopted by third-space endoscopy-trained thoracic surgeons.