Peroral endoscopic myotomy (Z-POEM) versus flexible endoscopic septotomy (FES) for treatment of Zenker's diverticulum: does either make the cut? A systematic review and meta-analysis of outcomes.

Background: Endoscopic treatments of symptomatic Zenker's diverticulum (ZD) include flexible endoscopic septotomy (FES) and, more recently, peroral endoscopic myotomy (Z-POEM). Data comparing these techniques are limited. We conducted a meta-analysis evaluating FES vs. Z-POEM for symptomatic ZD.

Methods: Multiple databases were searched from inception to September 2024. Our primary outcomes were clinical and technical success. Secondary outcomes included adverse events, length of hospital stay (LOS), procedure time, and recurrence. A random-effects model was used, and outcomes were represented as pooled rates, relative risk (RR) and standardized mean difference (SMD), along with 95% confidence intervals (CI).

Results: Seven studies with 580 patients (Z-POEM=274, FES=306) were included. Mean age ranged from 68.9-74.9 years. The diverticulum size was not statistically different between the 2 groups: SMD -3.78 (-11.68 to 4.12), P=0.35. The pooled technical success was similar for Z-POEM and FES: RR 0.99 (95%CI 0.96-1.02; =0%); P=0.4. Clinical success rate was significantly higher for Z-POEM compared to FES: RR 1.11 (95%CI 1.04-1.18; =16%); P=0.001. There were no statistically significant differences between the 2 treatment modalities in pooled rate of recurrence, adverse events, LOS or procedural time.

Conclusions: Our analysis shows that Z-POEM and FES in the treatment of symptomatic ZD are both associated with high technical success and a good safety profile, and have comparable procedural times and rates of recurrence. Z-POEM may offer higher rates of clinical success at follow up.