Endoscopic management of Zenker's diverticulum

Zenker's diverticulum (ZD) is a posterior hypopharyngeal mucosal and submucosal outpouching through an area of relative muscular weakness, known as Killian's triangle. It is an uncommon but highly treatable cause of mechanical dysphagia in elderly patients. Diagnosis is established by esophagography and upper endoscopy. The treatment has evolved with the advancement in the understanding of underlying pathophysiology. Traditionally, the management had been open surgical exposure and cricopharyngeal myotomy, combined with diverticular excision, suspension or inversion. Peroral endoscopic techniques (rigid and flexible) have gained popularity as minimally invasive and effective therapeutic options, with lesser mortality and morbidity. Flexible endoscopic myotomy offers additional benefits over rigid endoscopic techniques, as it does not require general anesthesia and neck hyperextension. The initial results of flexible endoscopy are quite encouraging, but long-term data are not yet available. For the optimal outcome, flexible endotherapy requires a formidable endoscopic skill, sound knowledge of the neck anatomy and meticulous understanding of the electrosurgical principles. In this article, we have comprehensively reviewed the current understanding of the pathophysiology involved and various techniques used in the management of ZD, with a focus on flexible endoscopic techniques.