Flexible versus Rigid Endoscopic Therapy for Zenker’s Diverticulum: A Retrospective Cohort Study

Abstract Endoscopic therapy has become first-line treatment for Zenker’s diverticulum (ZD). However, evidence comparing rigid and flexible endoscopic approaches remains limited. We therefore retrospectively compared both techniques in a tertiary university hospital. All consecutive patients receiving treatment for ZD from January 2009 to December 2024 were included. Patients underwent either rigid endoscopic CO2 laser myotomy (R-group) or flexible endoscopic myotomy using a needle knife (F-group). The primary endpoint was clinical improvement after completion of all clinically indicated interventions. Secondary endpoints were clinical improvement after the index intervention, procedure time, hospital stay, recurrence, reintervention and adverse events. A total of 156 patients were included (F-group, n = 100; R-group, n = 56). Clinical improvement after completion of all clinically indicated interventions was achieved significantly more frequently in the F-group than in the R-group (89.0 vs. 65.6%; p = 0.0063). In contrast, clinical improvement after the index intervention did not differ significantly between groups (65.8 vs. 56.3%; p = 0.386), while reintervention was more frequent in the F-group (27.4 vs. 18.8%). Mean intervention time (31.7 ± 13.3 vs. 40.8 ± 16.2 min; p < 0.001) and postinterventional hospital stay (4.9 ± 2.3 vs. 7.4 ± 4.4 days, p < 0.0001) were shorter in the F-group. No significant differences in recurrence or complication rates between the two groups were detected. Flexible and rigid endoscopic therapy showed comparable safety. Flexible endoscopy was associated with shorter procedure time and hospital stay and higher clinical improvement after completion of all clinically indicated interventions, although this was not demonstrated after the index intervention and required more frequent reintervention.