Esophageal diverticulum: A clinical framework for patient-tailored endoscopic management

Table 1 Endoscopic techniques for esophageal diverticulum: Technical essentials, indications, advantages and drawbacks

Technique name	Core technology	Best indications	Advantages	Limitations/common complications
FESD	Uses flexible endoscope and electrocautery or laser to cut the diverticular septum	Zenker's diverticulum and Killian-Jamieson diverticulum, especially for relieving symptoms requiring repeated surgery and recurrent Zenker's diverticulum after open surgery	No need for anesthesia, minimal trauma	Relatively high recurrence rate compared to open surgery
POEM	Establishes a submucosal tunnel and cuts the muscle layer	Zenker's diverticulum (Z-POEM), especially in patients with esophageal motility disorders	Significant relief of dysphagia symptoms, short hospital stay, quick postoperative recovery, preferred method for elderly and frail patients	High incidence of postoperative reflux esophagitis, especially in patients with hiatal hernia
ESAD	Uses endoscopy and a special stapler to complete cutting and suturing in one step	Zenker's diverticulum, may also be suitable for esophageal diverticulum combined with superficial esophageal cancer	Fast operation, relatively low early systemic inflammatory response compared to laser group	Higher recurrence risk compared to laser group
ELD	Uses CO2/Holmium laser for precise vaporization and cutting of the septum	Zenker's diverticulum, especially recurrent, fibrotic, or anatomically complex cases	Excellent surgical field, short operation time, good intraoperative hemostasis, allows for greater reduction of the diverticulum, high cutting precision, low risk of damage to deeper fascial layers, high patient comfort during surgery, improved postoperative quality of life, suitable for most revision cases	Possibly higher long-term recurrence rate

FESD: Flexible endoscopic septal diverticulotomy; POEM: Peroral endoscopic myotomy; ESAD: Endoscopic stapler-assisted diverticulotomy; ELD: Endoscopic laser diverticulotomy.