Submucosal Injection-Guided Septotomy (SING) for the Treatment of Zenker's Diverticulum: A Multicenter Study of Over 100 Procedures (With Video).

BACKGROUND AND AIM: We present the first experience with the submucosal injection-guided septotomy (SING) technique, which integrates the principles of flexible endoscopic septotomy with submucosal endoscopy, applied in different phases of the procedure for the treatment of Zenker's diverticulum (ZD). METHODS: Prospectively collected data from consecutive ZD patients treated with SING at three Italian centers (October 2019-August 2024) were analyzed. The primary outcome was clinical success (CS; Kothari-Haber Score < 2 at 3 months), whereas secondary outcomes included technical success (TS), procedural time, adverse events (AEs), hospital stay, and time to recurrence (Kaplan-Meier method). We also performed subgroup analysis according to ZD dimension (large vs. small) and to soft diverticuloscope use. RESULTS: A total of 102 patients underwent SING (median age 74 years [IQR 68-81]; 69.7% male). Median diverticulum depth was 30 mm (IQR 25-40) and baseline KHS score 4 (IQR 3-6). CS was achieved in 98% (95% CI 93.6%-99.8%), with 7% (95% CI 2.9%-13.9%) experiencing symptom recurrence over a median follow-up of 370 days (IQR 297-747). Recurrence-free probabilities were 93.5% at 6 months, 92.0% at 12 months, and 92.0% at 24 months. TS was 100%, median procedural time 30 min (IQR 25-45), and AEs occurred in 3 patients (2.9%), all managed endoscopically. CONCLUSIONS: SING is a safe and effective endoscopic treatment for ZD. Prospective comparative studies with standard techniques are warranted.