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Background: Zenker's diverticulum (ZD), a posterior outpouching of mucosa through transverse cricophargyngeal muscle fibers, has a reported prevalence of 0.01% to 0.11%. ZD is associated with marked morbidity, with symptoms ranging from halitosis and food regurgitation to aspiration pneumonia and cachexia. Therapeutic management of ZD has evolved from open diverticulectomy to rigid endoscopy, and, most recently, flexible endoscopy utilizing cricophayrngeal myotomy (CPM) with diverticulotomy. Traditional open surgical and rigid endoscopic methods have been associated with high rates of symptomatic resolution, with acceptable rates of recurrence. There are, however, associated complications of bleeding and perforation, with these risks being amplified in this comorbid, aged patient population. Building upon the per oral endoscopic myotomy (POEM) A POEM-based minimal incision cricopharyngeal myotomy (CPM) technique has been developed, using a needle knife to dissect the cricopharyngeal bar by way of a 8 to 10 mm incision within the confines of the mucosa without an extended diverticulotomy (See image).
Aims: To evaluate the efficacy of endoscopic minimal incision CPM in the treatment of Zenker's Diverticulum.
Methods: Prospectively collected cohort of patients undergoing minimal incision needle-knife cricophargyneal myotomy under monitored anesthesia care at a single center tertiary referral center.
Subjects include patients with symptomatic ZD as demonstrated by radiographic and/or endoscopic evaluation. The main outcome measurements consisted of pre- and post dysphagia scores (0-4 with 0 as no dysphagia and 4 representing severe dysphagia) and any post-procedural complications, as determined by clinical review and telephone follow up.
Results: from January 2009 to November 2012, 8 patients underwent minimal incision CPM (see table). The mean age was 76 years (range 61-91 years; 63% male). Improvement in dysphagia was seen in 100% of patients, though complete resolution was seen only in 4 patients (50%). As this was a pilot program, all patients were hospitalized overnight for observation. Excluding mild subcutaneous emphysema in two patients, no procedurally related problems. Time to follow up ranged from 2 weeks to 17 months.
Conclusion: Minimal incision CPM is effective in management of Zenker's diverticulum, and demonstrates effective resolution of dysphagia . In our case series, no serious procedural or post-procedural complications occurred.
Results of Cricopharyngeal Myotomy

Case	Age/Sex	Dysphagia Pre-Procedure	Dysphagia Post-Procedure	Successful
1	84/Male	3	0	Yes
2	68/Male	3	1	Yes
3	70/Male	3	1	Yes
4	61/Female	2	0	Yes
5	75/Female	2	0	Yes
6	76/Male	3	1	Yes
7	83/Male	2	0	Yes
8	91/Female	4	2	Yes

Dysphagia Score: 0=no dysphagia; 1=able to swallow some solid foods; 2=able to swallow only semi-solid foods; 3=able to swallow liquids only; 4=total dysphagia.

Myotomy within minimal incision.