• Vaibhav Gupta, Stephen Gowing, Ahmad Khoja, S M Mahmudul Hasan, Sean S Higgins, Richard Liu, and Biniam Kidane.
• Section of Thoracic Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada; Division of Thoracic Surgery, Department of Surgery, Western University, London, Canada.
• J. Thorac. Cardiovasc. Surg. 2024 Dec 3.

ObjectiveZenker's diverticulum is a mucosal herniation at the pharyngoesophageal junction. While open surgical myotomy is the conventional treatment, robust evidence on third-space flexible endoscopic myotomy is lacking. We assessed safety, effectiveness and patient-reported outcomes of per-oral endoscopic myotomy (Z-POEM) in the largest reported single-centre experience with this technique.MethodsRetrospective cohort study was performed of consecutive patients undergoing Z-POEM in a tertiary hospital thoracic surgery practice from 2018-2024. Data collected included demographics, comorbidities, clinical and radiographic (pre/post-operative esophagram) outcomes, and validated patient-reported quality-of-life outcomes (Dakkak and Eckardt scores). Descriptive analyses were used to describe the population, outcomes, and complications. Aggregate and individual-patient symptom trajectories were charted over time.ResultsFifty-seven patients (57.9% female, n=33) with a mean age of 74 years underwent Z-POEM. Median diverticulum size was 2 cm (IQR 2-3). All patients reported subjective symptom improvement and showed complete resolution of obstructed barium flow on postoperative esophagrams. At median follow-up of 9 months, all Z-POEM patients reported clinically-important improvements in objective symptom scores, with symptom trajectories showing rapid and durable improvement up to 5 years postoperatively. Four patients (7%) experienced complications. Majority of the cohort (66.7%) was unsuitable for rigid stapled myotomy, mainly due to short diverticulum or limited neck/mouth movement. No patients required repeat myotomy.ConclusionWe demonstrate significant and sustained relief of patient-reported outcomes/symptoms following Z-POEM, including for small diverticuli, with low complication rates. Its safety and versatility has made it the new standard of care locally; Z-POEM can be adopted by third-space endoscopy-trained thoracic surgeons.Copyright © 2024. Published by Elsevier Inc.

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