Comparative effect between Zenker's peroral endoscopic myotomy and alternatives in the treatment of Zenker's diverticulum: a systematic review and meta-analysis.

Background: Zenker's diverticulum (ZD) is a rare outpouching of the pharyngeal mucosa in the upper oesophagus, predominantly affecting elderly patients. Historically, the management for ZD has been surgery, but less invasive endoscopic techniques have also emerged. One technique that has gained traction is Zenker's peroral endoscopic myotomy (Z-POEM), but there remains no clear consensus on the optimal modality. This study aimed to compare the effectiveness and safety of Z-POEM with alternative treatments, including flexible and rigid diverticulotomy.

Methods: A literature search across MEDLINE, Cochrane, and Scopus databases identified comparative studies evaluating ZD treatments, through October 2024. Outcomes included technical and clinical success, reintervention rates, and adverse events. Data were synthesized using a random-effects model, and heterogeneity was assessed with the I2 index. Subgroup analyses were performed for specific comparisons.

Results: Seven studies involving 747 patients met inclusion criteria. Technical success was high for both Z-POEM (97.4%) and alternatives (95.8%). Clinical success significantly favored Z-POEM (odds ratio [OR]: 2.14 [95% confidence interval: 1.42-3.21]). Reintervention rates were not significantly different and adverse event rates were comparable (9.4% for Z-POEM vs. 12.4% for alternatives), with fewer perforations in Z-POEM. Subgroup analysis revealed that Z-POEM maintained comparable technical success, reintervention, and adverse events rates and achieved significantly higher clinical success than flexible (OR: 2.20) and rigid diverticulotomy (OR: 1.98).

Conclusion: Z-POEM demonstrated superior clinical success compared to alternative techniques. However, the low quality of evidence underscores the need for well-designed studies to validate these findings, and guide treatment decisions for ZD.