Table 1.

Summary of flexible endoscopic Zenker’s diverticulum treatment

Procedure	Technique summary	Pros	Cons
Traditional FECM	•Single midline incision and division of entire septum •Incision extends to base of diverticulum	•Most available literature •Does not require submucosal tunnel	•Unable to assess myotomy completeness •Potentially higher recurrence rates∗
Flexible endoscopic cricopharyngeal myectomy8†	•Double incision technique resulting in wedge-shaped resection of septum	•May reduce recurrence rate∗ •Does not require submucosal tunnel	•Unable to assess myotomy completeness •Limited long-term data
Z-POEM	•Proximal mucosal incision and submucosal tunnel •Muscular septum is exposed before myotomy •Overlying mucosa left intact	•Ensures complete myotomy •May reduce recurrence rate∗ •Intact mucosal layer protects against leak∗	•Technically challenging •Limited long-term data •Closure within limited working space •Residual mucosal flap may cause dysphagia in large Zenker’s diverticula∗
Modified over the septum Z-POEM	•Z-POEM with mucosal incision and submucosal tunnel at level of septum	•Reduces submucosal tunnel and improves working space during closure •Ensures complete myotomy •May reduce recurrence rate and leak∗	•Technically challenging •Technique limited to small series and case reports •Residual mucosal flap may cause dysphagia in large Zenker’s diverticula∗
Modified Z-POEM with mucosotomy	•After modified Z-POEM, the mucosal flap is stabilized and incised to the base of the diverticulum •Entire incised area is closed	•Exposing the muscular septum allows complete myotomy •Reduces postprocedure dysphagia due to residual mucosal flap∗	•Additional technical challenges •Technique limited to case reports
Hybrid Z-POEM	•Used if submucosal scarring limits tunnel formation •Standard FECM performed until submucosal tissue visualized •Z-POEM technique then used to expose muscular septum	•Allows treatment of recurrent/residual Zenker’s diverticula •Exposing the muscular septum at the base of the diverticulum allows complete myotomy •May reduce recurrence rate∗	•Additional technical challenges •Technique limited to case reports

FECM, Flexible endoscopic cricopharyngeal myotomy; Z-POEM, Zenker’s peroral endoscopic myotomy.

^∗Perceived theoretical benefit; no high-quality data available.

^†Not included in video case series.