Long-term symptomatic control of Zenker diverticulum by flexible endoscopic mucomyotomy with the hook knife and predisposing factors for clinical recurrence

OBJECTIVE: Flexible endoscopic treatment for Zenker diverticulum (ZD) is well established. Although recurrence of symptoms is relatively frequent, it has hardly been studied. In the present study, we analyse the long-term development of ZD patients' symptoms after successful endoscopic mucomyotomy, as well as interventional safety, sustainability of success, and predisposing factors for clinical recurrence. METHODS: Forty-six consecutive patients (54% male, mean age 67 years) with symptomatic ZD were treated using a hook knife and soft diverticuloscope. Follow-up interviews at 1 and 6 months inquired about a broad pool of symptoms and the dysphagia score. For further analysis, patients were retrospectively stratified into a 'recurrence' and 'no recurrence' group. RESULTS: After 100% initial success, 30% of patients reported recurrence of symptoms after 4.4 months (range 1-40) and were re-treated (mean 1.39 sessions/patient). Though the 'recurrence' group showed a higher dysphagia score and frequency past intervention, endoscopic re-treatment achieved equally good results as in the 'no recurrence' group. Before treatment, 'recurrence' patients had more severe symptoms, such as vomiting (frequency score 2.13 vs. 0.92; p < 0.05), ZD-related insomnia (1.65 vs. 1.08, n.s.), and a higher dysphagia score (2.25 vs. 1.59, n.s.). Also, the 'recurrence' group had larger diverticula, more men, slightly younger age and a longer duration of symptoms. CONCLUSIONS: Endoscopic treatment of ZD with hook knife and soft diverticuloscope is safe and effective. Despite considerable clinical recurrence, re-treatment achieved a long-lasting freedom of symptoms. Male patients with a high dysphagia score and severe symptoms were more likely to experience recurrence.