Outpatient Flexible Endoscopic Diverticulotomy for Management of Zenker's Diverticulum - A Retrospective Observational Study From Single Center

Introduction: Zenker’s diverticulum (ZD) is an acquired condition that develops due to abnormally high pressures during swallowing, leading to outpouching of mucosa and submucosa within the pharyngoesophageal junction. In those presenting with dysphagia, regurgitation, halitosis, or weight loss, ZD can be diagnosed with barium swallow or endoscopy. Flexible endoscopic diverticulotomy is an established procedure for ZD. The aim of our study was to assess the safety and efficacy of outpatient flexible endoscopic diverticulotomy for ZD. Methods: All patients who had a flexible endoscopic diverticulotomy at Vancouver General Hospital (VGH) between April 1, 2012 and May 31, 2023 were included. Retrospective chart review was conducted to obtain patient demographic and procedural and post-procedural management data. Any complications during and after the procedure were included. Results: 38 patients were included with 46 flexible endoscopic diverticulotomies performed. 24 patients (63.2%) were male, and median age was 78.5 (range 51 to 103) at the time of procedure. Majority of patients (73.7%) had a Charlson Comorbidity score of 3 or higher. Only 1 patient was an active smoker, and none had excessive alcohol use history. Dysphagia, regurgitation, and heart burn were most common symptoms present at the time of referral (91.3%, 71.7%, and 58.7%, respectively). 10 (21.7%) had previous interventions for ZD – 8 of which were with flexible endoscopic diverticulotomy. 12 procedures (26.1%) were performed under conscious sedation and 34 (73.9%) under general anesthetic. 5 patients (10.9%) had intraprocedural bleeding, that did not require transfusions. 3 patients (6.8%) developed subcutaneous emphysema within 2 hours post-procedure, and were managed conservatively without further endoscopic or surgical intervention. 33 patients (71.7%) were discharged on the same day of procedure, with an additional 6 (13.0%) discharged within 2 days post-procedure. Median follow-up was 74 days (range 0-2472 days). Conclusion: Endoscopic flexible diverticulotomy is a safe procedure for the management of Zenker’s Diverticula. Patients with immediate complications, including intraprocedural bleeding or presence of subcutaneous emphysema within 2 hours post-procedure, were associated with hospital stay longer than 1 day. None of the patients developed late complications or required readmission within 30 days of discharge. Therefore, outpatient ZD management is effective in both patient management and resource allocation.