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Scardino et al. Mini-invasive Surg 2022;6:57  https://dx.doi.org/10.20517/2574-1225.2022.55  Page 5 of 9

               Table 3. Literature review and personal experience with Z-POEM and Z-POES
                                                             Technical   Clinical               Follow-up
                                                     No. of                    Adverse events
                Author         Study design  Technique       success   success                  range,
                                                     patients  (%)     (%)     (%)              months
                Maydeo et al., 2019 [53]  Retrospective   Z-POEM  20  100  86  No serious AE    0-12
                               single-center
                Kamal et al., 2020 [54]  Meta-analysis  Z-POEM  233  95  NR    6                NR
                          [55]
                Yang et al., 2020  Retrospective   Z-POEM  75  97.3    92      6.7              3.4-14.5
                               multicenter                                     (1 bleeding, 4
                                                                               perforations)
                           [56]
                Sanaei et al., 2020  Retrospective   Z-POEM  32  93.8  96      12.5             NR
                               multicenter                                     (2 leaks)
                Al Ghamdi et al.,   Retrospective   Z-POEM  91  NR     95      6                3-7.5
                2020 [57]      multicenter
                           [31]
                Repici et al., 2020  Retrospective   Z-POES  20  100   95      No serious AE    6-20
                               single-center
                            [58]
                Klingler et al., 2020  Retrospective   Z-POES  19  94.7  89.5  10.5 (2 perforations,1   4.7-15.5
                               single-center                                   retropharyngeal abscess)
                Spadaccini et al.,   Systematic   Z-POEM,   196  96.9  93.4    4.9              NR
                2021 [32]      review      Z-POES
                Personal experience   Retrospective   Z-POES  17  100  94.2    5.8 (1 leak)     3-41
                [University of Milan,   single-center
                IRCCS Policlinico San
                Donato]
               AE: Adverse event; NR: not reported; Z-POEM: Zenker peroral endoscopic myotomy; Z-POES: Zenker peroral endoscopic septotomy.
























                Figure 2. Z-POES: Mucosal incision and exposure of the cricopharyngeus (left); and visualization of the buccopharyngeal fascia after
                myotomy (right).

               Over the past two decades, a total of 271 patients have been treated for ZD at our esophageal center. Of
               these individuals, 20 (7.4%) underwent open surgery and 198 (73%) transoral stapling through rigid
               endoscopy. Overall, 53 (19.6%) patients underwent a flexible endoscopic procedure, 17 (32%) of whom were
               treated with Z-POES. The technical success rate of the procedure was 100%, and the clinical success rate was
               94.2%. One patient developed a subclinical leak which was treated conservatively with antibiotics and
               naso-enteral nutrition.

               DISCUSSION
               The development of transoral techniques has allowed a minimally invasive and precise approach to treating
               ZD. However, anatomical characteristics of patients, small pouches, and lack of physician’s expertise with
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