Historically, treatment of ZD has evolved from surgical to rigid endoscopic and now to flexible endoscopic approaches. Early treatment was often diverticulectomy through a neck incision. As understanding of pathophysiology evolved, it became apparent that increased hypopharyngeal bolus pressures were a result of decreased compliance of the cricopharyngeus muscle and that disruption of the muscle was necessary to prevent recurrence [10]. With the open approach, pouches >5 cm in length are often excised with stapled closure of the defect. Pouches 25–50 mm are often treated with diverticulopexy and CP myotomy. Smaller diverticula may be treated with diverticulopexy or just CP myotomy alone. The open approach is associated with a 10.5% rate of morbidity, but good success rates, with resolution of symptoms in about 95% of patients [11].

The rigid transoral approach utilizes a diverticuloscope, which acts as a speculum with its long blade in the esophagus and its short blade in the diverticulum, exposing the common wall. Division of the common wall (including the cricopharyngeus) is then performed using anything from electrocautery, carbon dioxide laser, ultrasonic dissection, or stapling [11]. The idea is to incise the common wall (formed at the top by the cricopharyngeus muscle and perpetuated by the adhesion of the posterior esophageal wall to the anterior aspect of the diverticular sac) (Fig. 8.2). The diverticulum thus becomes contiguous with the posterior wall of the esophagus. Comprehensive reviews of this approach confirmed similar rates of clinical success compared to the open approach (90%), but with slightly lower morbidity (7%), and so this methodology has become the current standard [11].

Some patients may not be candidates for the rigid transoral approach for anatomic reasons such as inadequate neck mobility, upper teeth protrusion, or inadequate jaw opening. Flexible endoscopic techniques have emerged, especially over the last decade, utilizing a variety of technologies. The first case was performed in 1982, but recently there has been a resurgence of interest as an exploding array of endoscopic tools has become available [12, 13]. Prophylactic antibiotics are frequently used, and patients are kept nil per os (NPO) prior to the procedure. The use of a soft diverticuloscope improves maneuverability and is associated with a lower risk of perforation and a higher likelihood of technical success on the first procedure [14] (Fig. 8.3). Another option would be to utilize a transparent cap that can be attached to the tip of the endoscope, as is often done in endoscopic submucosal dissection (ESD). A guidewire or nasogastric tube may be placed in the stomach, which also serves to guide the incision from the diverticulum to the esophageal lumen, although we find it is typically not necessary. A variety of endoscopic tools can be used to incise the common wall, including a needle knife (multiple manufacturers), the Hybrid Knife^® (Erbe USA, Marietta, GA), Hook Knife™ (Olympus America, Center Valley, PA), hot biopsy forceps, or argon plasma coagulator (APC™) (Erbe USA). No particular incisional device was found to be superior, but most studies have been relatively small and underpowered to detect these differences [15]. The most important landmark to identify is the muscular septum between the true lumen and false lumen. The incision is begun with a mucosotomy performed over the cricopharyngeus muscle (Fig. 8.4). This exposes the underlying muscle (Fig. 8.5). All muscle fibers are then divided to complete the myotomy (Fig. 8.6). The incision is then carried down further until the septum is completely incised. An endoscopic clip is typically placed at the vertex of the incision and is thought to decrease the risk of subsequent perforation, or the incision is closed on both sides with multiple clips (Fig. 8.7). Patients are either NPO or allowed to have liquids post-procedure, and the diet is generally advanced that evening or the next day. Barium swallow evaluations were historically obtained after septotomy, but findings generally did not correlate well with clinical outcomes [16]. Therefore, some surgeons are abandoning this practice.

Great technological variety has lead to significant heterogeneity in the published literature regarding flexible endoscopic therapy, but overwhelmingly results are at least comparable to other modalities. A recent publication found that septotomy length ≤25 mm and diverticulum size ≥50 mm were associated with clinical failure at 6 months [17]. Post-procedural radiographic appearance does not correlate well with symptoms as noted above, but the presence of a post-treatment diverticulum ≥10 mm was associated with clinical failure at 48 months. Success rates were best for diverticula measuring 30–49 mm and a septotomy >25 mm with 100% clinical success at 6 months.