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Page 2 of 9 Scardino et al. Mini-invasive Surg 2022;6:57 https://dx.doi.org/10.20517/2574-1225.2022.55

[3]
progressive population aging . Common symptoms are dysphagia and regurgitation, and the most frequent
[4]
complication is recurrent aspiration pneumonia . It has been estimated that the ZD annual average
[5]
caseload is 8.7 patients per year .
Historically, surgical treatment of ZD consisted of surgical resection of the pouch. Only during the last five
decades has the crucial role of the cricopharyngeal muscle been recognized, and cricopharyngeal myotomy,
performed either surgically or endoscopically, has become the main target of treatment. The developments
of minimally invasive surgery and endoscopic technologies, including rigid and flexible endoscopy, have led
to profound changes in management . Most importantly, the recent introduction of Zenker peroral
[6,7]
endoscopic myotomy (Z-POEM) reflects a better understanding of the pathophysiology of the disease and
the need to minimize recurrence rates and improve the quality of life in these patients. In this review, we
analyze the current status of minimally invasive transoral management of ZD.

EVOLUTION OF TREATMENT (1): FROM OPEN TO TRANSORAL SURGERY
Zenker diverticulum was initially treated by open surgery or rigid endoscopy, respectively, with the aim to
resect the pouch or divide the septum between the esophagus and the diverticulum. Surgical procedures for
ZD have been refined and progressively standardized using a stapler to reduce the incidence of leaks. Over
time, the importance of adding a cricopharyngeal myotomy to surgical resection of the pouch has been
recognized as a critical component of the surgical procedure to minimize leaks and reduce anatomical and
symptomatic recurrences [Table 1].
[8]
This has encouraged the development of minimally invasive transoral techniques to divide the common
septum using mainly electrocautery or CO laser . At the beginning of the laparoscopic era, transoral
[9]
2
stapling revolutionized the therapeutic approach to ZD. The procedure, first proposed by Collard ,
[10]
Martin-Hirsch , and Narne in 1993, consisted of division of the septum by an endoscopic linear
[11]
[12]
endostapler introduced through a rigid Weerda diverticuloscope under general anesthesia. This technique
showed excellent clinical outcomes, especially in patients with large-sized (> 3 cm) diverticula [Table 2]. In
addition, restoration of pharyngoesophageal physiology was shown by manometric and scintigraphic
studies showing decreased hypopharyngeal intrabolus pressure and improved upper esophageal sphincter
clearance . However, placement of the rigid diverticuloscope and actioning of the endostapler might be
[13]
[14]
difficult in patients with neck stiffness or limited mouth opening . In addition, the procedure is not
indicated in patients with small diverticula (< 3 cm) because of the inability to engage enough
cricopharyngeal muscle tissue for stapling over the entire length of the septum [15,16] . A multicenter study
from the UK on 585 patients operated by otolaryngologists showed a conversion rate of 7.7%, an overall
complication rate of 9.6%, and a recurrence rate of 12.8% . Over the years, a modified endostapling
[17]
technique using a traction suture on the apex of the septum was proposed to add an average of 1 cm of
septum length into the stapler jaws, thus enabling extended septal division [18,19] [Figure 1]. In addition,
various cutting and coagulation devices, including Harmonic scalpel and LigaSure, were introduced to
provide complete septum division at least 1 cm distal to the uncut suture line. Soft overtubes have also been
[20]
proposed to obviate the difficulties in positioning the rigid diverticuloscope .
EVOLUTION OF TREATMENT (2): FROM STANDARD FLEXIBLE ENDOSCOPY TO THIRD-
SPACE ENDOSCOPY
Although transoral stapling has been the preferred initial approach for ZD, lack of expertise with the rigid
transoral approach, anatomic limitations of septum exposure such as reduced neck extension or inadequate
mouth opening, and the requirement for narcosis have encouraged the development of flexible endoscopic
techniques. Flexible endoscopic septotomy (FES) has quickly gained popularity since the first report by