Peroral endoscopic myotomy for recurrent Zahnker's diverticulum, following endoscopic myotomy. These are our disclosures 49-year-old male with past medical history of gastroesophageal reflux disease, presented with asymptomatic Zahnker's diverticulum. Patient noted 2 years of intermittent dysphagia to solids and at times to liquids, mild sore throat and hoarseness. ENT performed an initial rigid endoscopy with planned Zahnker's myotomy. However, despite multiple attempts, the septum was not visualized and the procedure was aborted. Patient was referred to GI. Flexible endoscopic myotomy was scheduled. This is an esophageogram showing the Zahnker's diverticulum. The Zahnker's diverticulum was not pronounced. Therefore, standard flexible endoscopic myotomy was performed. Zahnker's diverticulum with a small opening, no impacted fluid and no stigmata of recent bleeding was found. A guide wire was placed into the esophageal lumen, followed by placement of an orogastric tube to better orient the Zahnker's diverticulum and expose the septum. At the center of the septum, a perpendicular incision into the submucosal space was made using the dual knife and the IT2 knife. Myotomy was performed through the circumferential muscle fibers and extended to the base of the diverticulum. After dissection, two hemoclips were applied to the base of the incision, closing the mucosotomy defect. Patient noted immediate symptom relief post-flexible endoscopic myotomy. Two months later, recurrent dysphagia was noted. Symptoms subsequently progressed. Repeat esophageogram revealed the recurrent persistent Zahnker's diverticulum. Endoscopy planned with potential repeat myotomy. A gastroscope was passed into the esophagus. The septum between the Zahnker's diverticulum and the esophageal lumen was identified. The remaining septum was noted with evidence of the prior septotomy scar. Zahnker's diverticulum was found at the level of the cricopharynges. The Zahnker's diverticulum was more pronounced. The septum was better visualized. Therefore, a ZIPO procedure was performed. The center of the septum was injected with a methylene blue saline solution. A good lift was noted at the prior septotomy scar site. Ilongitudinal mucosotomy along the septum was performed with a dual knife. Intermittent injection of saline and methylene blue solution was done into the Zahnker's and the esophageal submucosal sides of the septum. Subsequent submucosal diagnosis was performed. Subsequent submucosal dissection was performed. Dissection was made on both sides of the septum, the Zahnker's side and the esophageal side, until reaching the base. Once dissection was performed, the full septum was exposed. Mucotomy was performed through the circumferential muscle fibers under direct vision until all fibers were obliterated. The tunnel was examined for vessels. Any high-risk vessels were treated with coagulation coterie. The mucosotomy was closed with hemostatic clips. Flexible endoscopic myotomy can be effective as an alternative intervention when rigid endoscopy cannot be technically performed. Endoscopic assessment may reveal a small Zanker's diverticulum with a less pronounced septum. Standard flexible endoscopic myotomy can be safely performed. Repeat endoscopic assessment is important in recurrent, persistent Zanker's diverticulum post-initial myotomy. Z-POEM is a viable rescue intervention in patients that have previously undergone flexible endoscopic myotomy. Z-POEM is generally a safe and effective method for treating symptomatic Zanker's diverticulum.

Zahnker's diverticulum

rigid endoscopy

flexible endoscopic myotomy

recurrent dysphagia

Z-POEM procedure