The open surgical approach is associated with adverse events, including fistulae and infection. A transoral approach lessens these risks by avoiding an incision. In experienced hands, flexible or rigid endoscopic diverticulotomy is currently considered as a first-choice option in the management of ZD because it gives symptom relief comparable to open surgical diverticulectomy with less morbidity, shorter hospital stay, and, in the case of a flexible endoscopic approach, without the need of general anesthesia.

Rigid endoscopic diverticulectomy is carried out by dividing the common wall with a rigid diverticuloscope. The methods adopted to divide the common wall have evolved from electrocautery to carbon dioxide laser therapy to the now more commonly performed stapling [1].

Flexible endoscopy shares the same principles as rigid endoscopy: it consists of dividing the septum thus creating a common cavity. However, the technique still needs to be standardized because a variety of different modalities and endoscopic devices have been used, including freehand cut, guidewire-assisted and diverticuloscope-assisted myotomy, argon plasma coagulation, monopolar forceps, and needle knife for cutting the septum [3–10]. In this line, three different needles have been used: a standard needle knife [5], the hook knife [6] (Fig. 11.4), and most recently the IT knife 2 [7] (Fig. 11.5). Flexible endoscopic treatment of ZD can be performed in deep sedation with propofol or under general anesthesia and endotracheal intubation according to local practice. Antibiotic prophylaxis is recommended in high-risk patients. A soft diverticuloscope (ZD overtube; Cook Endoscopy, Winston − Salem, North Carolina, USA) (Fig. 11.6) permits to expose, stretch, and fix the septum (Fig. 11.7). It has two distal flaps of 40 and 30 mm that protect the anterior esophageal and posterior diverticular wall, respectively. The overtube is advanced over the endoscope up to a black marker indicating the average distance between the septum and teeth line. Under endoscopic vision, the septum is displayed [5]. Once the septum is properly exposed, different cutting methods can be applied. Myotomy can be done using standard needle knife, monopolar forceps, argon plasma coagulation, hook knife, or, most recently, IT knife 2 [3–10]. IT knife 2 seems to guarantee a more precise cut compared with other devices, allowing a more stable position by putting the insulated rounded tip on the septum of the diverticulum and cutting it toward a caudal direction (Figs. 11.8 and 11.9). In our study [7], 21 procedures in 19 patients were performed registering two dysphagia recurrences (in the first two cases) and no complications.