Dear Editor,

In a recent paper entitled ‘Zenker’s diverticulum: Rotterdam experience’ Visser et al. [1] conclude that endoscopic modalities remain the treatment of choice, because research has proven these methods to be favoured over transcervical approach. However, they do not refer to the 2015 review of Verdonck and Morton [2], where reported failure from open and endoscopic approaches was 4.2 and 18.4%, respectively. Corresponding complication rates were 11 and 7%. Visser et al. [1] actually report an overall failure rate of 55% with stapler and 50% with laser. Some of these failures are related to the need to abort the index procedure and others relate to recurrence.

Visser et al.’s small series of six transcervical cases all involved sac excision. Certainly when considering the transcervical approach, sac excision carries increased risk when compared with sac inversion [2]. Nevertheless, if one takes into account the review of the literature [2], while open approaches and stapler diverticulotomy may yield different patterns of complications, endoscopic and external approaches are generally at least comparable [2]. Indeed, the open approach in some situations has real benefits over endoscopic treatment and certainly all patients can be managed by an open approach.

Our personal experience with sac inversion (recurrence rate of 2.4% and complication rate of 9.8%) [3] would suggest that in experienced hands—despite the surgery taking a little longer (average operating time 78 min)—this technique is to be preferred over the endoscopic approach.