Analysis of patient outcomes after flexible endoscopic Zenker diverticulotomy

Oct. 31, 2023

Zenker diverticulum (ZD) is caused by dysfunction of the cricopharyngeal muscle at the junction of the pharynx and the esophagus. Although mild cases can be asymptomatic, ZD can cause dysphagia, regurgitation, halitosis, coughing, aspiration and weight loss.

Treatment of symptomatic Zenker diverticulum (ZD) Treatment of symptomatic Zenker diverticulum (ZD)

A. Diverticular septum relative to Zenker pouch (left) and esophageal lumen (right). B. Post-flexible endoscopic diverticulotomy (septotomy) with easier endoscope passage into the esophagus.

Several surgical and endoscopic options are available for the treatment of symptomatic ZD. Current minimally invasive approaches include both flexible and rigid endoscopic procedures. Flexible endoscopic Zenker diverticulotomy (FEZD) is performed by passing the endoscope to the level of the diverticulum, allowing the endoscopist to divide the cricopharyngeus using a variety of methods.

FEZD is the only endoscopic option available for patients with limited neck extension, large cervical osteophytes and other anatomical constraints in whom rigid endoscopic diverticulotomy is not feasible or safe. For select patients, FEZD can be performed under conscious sedation and also may allow for same-day discharge.

Mayo Clinic endoscopists have performed FEZD in patients with Zenker diverticulum since 2006, amassing one of the largest single institutional experiences using this method. Noting that most prior investigations of FEZD lacked large sample sizes, Mayo Clinic researchers conducted a retrospective review of FEZD outcomes in 75 patients. Gastroenterologist Louis M. Wong Kee Song, M.D., and co-investigators published the study results in the American Journal of Otolaryngology in 2023. Dr. Wong Kee Song is a therapeutic endoscopist and researcher at Mayo Clinic's campus in Rochester, Minnesota, and a lead author on the study publication.


The researchers identified 75 patients who underwent a total of 84 FEZD procedures for treatment of symptomatic ZD at Mayo Clinic from 2006 to 2021. Using data extracted from clinical notes, endoscopic procedure reports and radiographic swallow study reports, the researchers recorded patient demographics, clinical features, procedural characteristics, adverse events and outcomes.


  • Of the 84 procedures analyzed, 67.9% were performed under general anesthesia and 32.1% under monitored anesthesia care.
  • A total of 56.4% of patients were discharged, and 57.1% of patients resumed oral intake on the day of the procedure.
  • There were 16 procedure-related adverse events (19.0%), conservatively managed in all but one case. These included minor intraprocedural bleeding (15.7%) controlled with endoscopic means, infection (4.8%), subcutaneous emphysema (2.4%) and microperforation (10.7%).
  • Among the 75 patients involved in the study, 97.6% sustained subjective improvement in symptoms after the procedure.
  • Only 20% of patients experienced symptomatic recurrence of ZD after undergoing initial FEZD, 26.7% of whom were successfully treated with repeat FEZDs. The average time to recurrence was 2.8 years. Younger age was associated with symptom recurrence.

"Overall, our study suggests that FEZD is an effective, safe method of treating symptomatic ZD," notes Dr. Wong Kee Song. "Our data demonstrates that this approach is an appropriate alternative for patients in whom otorhinolaryngological procedures via rigid endoscopy are not an option. Prospective randomized trials that evaluate the relative benefits and risks of flexible versus rigid endoscopic approaches for symptomatic ZD are warranted."

For more information

Aden A, et al. Flexible endoscopic Zenker's diverticulotomy — A retrospective review of outcomes in 75 patients. American Journal of Otolaryngology. In press.

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