Zenker’s Peroral Endoscopic Myotomy (Z-POEM) is a minimally invasive, endoscopic procedure for the treatment of Zenker diverticulum. Here’s a step-by-step guide to help you successfully perform your first Z-POEM.

Step 1: Patient Selection

• Ideal candidates: Patients with symptomatic Zenker diverticulum, particularly those with significant dysphagia or recurrent aspiration.
• Exclude patients with contraindications to endoscopy or severe comorbidities.

Step 2: Preparation

• Equipment:
  • Diagnostic gastroscope (Olympus EVIS X1, GIF 190) with a soft distal cap (Fuji DH-28GR).
  • Electrocautery device: ESG-300 (Olympus, Tokyo, Japan) with the following setting: PulseCut Fast 100W, Effect 2 and ForcedCoag 40W, Effect 2 for both incision / myotomy and dissection
  • Dissection knife: DualKnife (Olympus, Tokyo, Japan).
  • Carbon dioxide insufflator.
  • Hemostatic clips for mucosal closure.
• Patient positioning: Left lateral decubitus under general anesthesia with endotracheal intubation.
• Administer prophylactic antibiotics to reduce the risk of mediastinitis.

Step 3: Entry to the Submucosal Space

• Mark the mucosa 2–3 cm proximal to the diverticular pouch.
• Use the knife to create a longitudinal incision, exposing the submucosal layer.
• Initiate submucosal tunneling using electrocautery, keeping the diverticular septum in view.

Step 4: Myotomy

• Identify and dissect the cricopharyngeal muscle fibers along the diverticular septum.
• Ensure complete myotomy without extending beyond the septum to avoid perforation.

Step 5: Mucosal Closure

• Carefully close the mucosal entry with hemostatic clips to prevent leakage and expedite healing.

Step 6: Postoperative Care

• Observe the patient for 24–48 hours to monitor for complications, such as perforation or infection.
• Initiate a liquid diet, gradually advancing to solids as tolerated.

Tips and Tricks for Success

• Use of submucosal injection: A combination of saline and blue methylene facilitates clear visualization of the layers.
• Controlled dissection: Avoid excessive energy application to reduce thermal injury.
• Manage bleeding promptly: Use coagulation forceps or hemostatic spray as needed.
• Build confidence gradually: Start with smaller diverticula before tackling complex cases.

Potential Challenges

• Bleeding: Be prepared with hemostatic tools (coag-grasper, etc.).
• Perforation: Ensure meticulous technique and readiness for endoscopic closure.
• Suboptimal visualization: Adjust cap position or use a water jet as necessary.

With the right preparation and practice, Z-POEM can become a safe and effective procedure in your therapeutic endoscopy repertoire!