Z-POEM technique

Standard peroral endoscopic myotomy technique for Zenker's diverticulum (Z-POEM).
(A) A ZD (arrow Zenker's diverticulum; dashed arrow septum) is identified.
(B) A mucosal bleb is created 2 cm above the septum.
(C) A submucosal tunnel is created using spray coagulation and injection of saline/indigo carmine solution via the pump. Once the septum is exposed, the septotomy is performed using an endoscopic submucosal dissection knife with an insulated tip.
(C-E) The septotomy is extended until the longitudinal muscle fibers of the esophagus proper are exposed (thick arrow).
(F) The mucosal incision is closed using through-the-scope clips.