Reply to Dr. Mandavdhare

We thank Dr. Mandavdhare for his comments on our study on flexible endoscopic myotomy for Zenker’s diverticulum [1] and would like to clarify the concerns raised.

The letter accurately highlights similar technical and clinical success rates between the traditional myotomy and submucosal dissection groups, but incorrectly suggests higher adverse events in the submucosal dissection group (16.7 % vs 6.6 %; P = 0.11), there being no statistically significant difference for any of the procedural outcomes (technical/clinical success, or adverse events) between the groups. We acknowledge that these results may be limited by the small number of patients in the submucosal dissection group and do need further validation. Also, the letter inaccurately assumes that the Zenker’s diverticula were larger in the submucosal dissection group, leading to higher adverse events. In fact, the mean Zenker’s diverticulum size was similar in the traditional myotomy and submucosal dissection groups (2.9 cm [range 0.5 – 7] vs 2.2 cm [range 0.5 – 4], respectively; P = 0.98). Finally, the claim that small Zenker’s diverticula (< 2 cm) should be treated with endoscopic submucosal dissection on the septum (or POES) [2], while larger Zenker’s diverticula need Z-POEM, cannot be substantiated in the absence of direct head-to-head data. There are no prospective randomized studies comparing or favoring these “third space” techniques for Zenker’s diverticula, although the newer techniques may allow a complete septotomy, eliminating recurrence.

In summary, all approaches for flexible endoscopic myotomy for Zenker’s diverticulum offer excellent results in experienced hands. It is the end result of severing the septum that is important. We believe that POES and Z-POEM are safe and effective for all Zenker’s diverticula and can be performed in around 30 minutes (personal experience of M.S.W.), a theme shared by others in the field [2] [3] [4]. However, until prospective comparative studies with long-term follow-up become available, it would be a leap of faith to assume that one flexible endoscopic approach for Zenker’s diverticulum is preferred over another.

Publication History

Article published online:
29 March 2021

• References

• 1 Mittal C, Diehl D, Draganov P. et al. Practice patterns, techniques, and outcomes of flexible endoscopic myotomy for Zenker’s diverticulum: a retrospective multicenter study. Endoscopy 2021; 53
• 2 Repici A, Spadaccini M, Belletrutti PJ. et al. Peroral endoscopic septotomy for short-septum Zenker's diverticulum. Endoscopy 2020; 52: 563-568
• 3 Wagh MS, Draganov PV. How to approach a patient with a Zenkerʼs diverticulum. Gastroenterology 2020;
• 4 Khashab MA. Response to Ishaq et al. Gastrointest Endosc 2020; 91: 205-206