Dear Editors,

We read with great interest the paper titled ‘A multi-centre analysis of a decade of endoscopic pharyngeal pouch surgery in Cheshire and Merseyside’ by the Mersey ENT Trainee Research Collaborative,^{Reference Hampton, Allan, Pearson, Emerson, Jones and Junaid1} in your esteemed journal. We would like to commend the authors for their contribution to the overall limited knowledge available on the endoscopic treatment of pharyngeal pouches, and it is heartening to see the trainee collaborative model at play, involving six separate centres and adopting a common, pre-defined audit standard. This article, however, raises some questions that we struggle to find answers to, and would like to offer some recommendations with the intention of adding to the body of knowledge that this paper provides.

In their publication, the authors mentioned that they only used a crude assessment of patient-reported symptom improvements, instead of utilising any symptom assessment tools to evaluate patients pre- and post-procedure. The validated Dysphagia, Regurgitation and Complications Scale scoring tool^{Reference Ishaq, Siau, Lee, Sultan, Mohaghegh and Kuwai2} is superior to the dysphagia score alone for assessing Zenker's diverticulum. Of note, regurgitation can be a particularly disabling symptom even in the absence of dysphagia. Such a comprehensive assessment tool (the Dysphagia, Regurgitation and Complications Scale)^{Reference Ishaq, Hassan, Antonello, Tanner, Bellisario and Battaglia3} is useful in providing an objective measure to quantify the severity of symptoms pre-procedure and to determine the degree of benefit a patient receives as a result of the procedure.

Secondly, the technical and clinical success have not been clearly defined in the methods. We also struggled to identify how long these patients were followed up post-procedure, making it difficult to extrapolate the true recurrence rate. The authors could include the median follow-up duration to allow better interpretation of recurrence rate over time.

Finally, the authors focused primarily on endoscopic stapling as the endoscopic pharyngeal pouch surgery method, but did not include other alternative procedures, such as flexible endoscopic septum division^{Reference Ishaq, Hassan, Antonello, Tanner, Bellisario and Battaglia3,Reference Ishaq, Sultan, Siau, Kuwai, Mulder and Neumann4} which is also being used to treat pharyngeal pouches. A meta-analysis^{Reference Ishaq, Hassan, Antonello, Tanner, Bellisario and Battaglia3} of flexible endoscopic septum division has shown it to be at least comparable in terms of abandonment rate (7.7 per cent), success rate (90 per cent), complication rate (6.2 per cent), perforation rate (4.8 per cent) and recurrence rate (11 per cent), in the treatment of pharyngeal pouches without the use of general anaesthetic. Given the lack of general anaesthetic usage, flexible endoscopic septum division may be the procedure of choice for patients with significant co-morbidities. We invite the authors’ views on the observations discussed above.