BACKGROUND:

Flexible endoscopy septotomy for Zenker's diverticulum (ZD) is an alternative to endostapling. However, long-term data are sparse and studies are heterogeneous. The aim was to assess the clinical success of flexible endoscopy diverticuloscope-assisted septotomy according to all ZD-related symptoms and identify potential prognostic variables.

METHODS:

Prospective database of all patients with ZD undergoing septotomy followed up for ≥24 months were analyzed. Septotomy was conducted by the diverticuloscope-assisted technique. Dysphagia, regurgitation and respiratory symptoms (day and night time) were scored by their weekly frequency from 0 to 3 on a solid food diet. Clinical success (asymptomatic state) was defined as a maximum of two symptoms with score 1 (once per week). Prognostic variables of clinical success included age, sex, pre-treatment total symptom score, pre- and post-treatment ZD size, and septotomy length. Kaplan-Meier method and Cox proportional-hazards model were used to calculate the crude and adjusted Hazard Ratio (HR).

RESULTS:

Septotomy was attempted and achieved in 89 patients in a single session. Clinical success at the ITT analysis was 69%, 64%, and 46% at 6, 24, and 48 months, respectively. Adverse events occurred in 3 cases: perforation in 2 (2%) and post-procedural bleeding in 1 (1%). Independent variables for failure at 6 months were septotomy length ≤25 mm (HR 6.34) and pre-treatment ZD size ≥50 mm (HR 11.08); whereas at 48 months were septotomy length ≤25 (HR 2.20) and post-treatment ZD size ≥10 mm (HR 2.03). Success rates for ZD ranging from 30 mm to 49 mm with a septotomy >25 mm were 100% and 71% at 6 and 48 months, respectively.

CONCLUSIONS:

Flexible endoscopic septotomy for ZD is feasible and safe. Success in treatment correlates with length of septotomy and size of ZD that should ultimately tailor the appropriate approach.