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[34]
rigid endoscopy represent limitations of the transoral stapling technique . Both Z-POEM and Z-POES
appear safe and effective and may prove superior to the standard flexible endoscopy technique because they
provide direct exposure of the cricopharyngeal muscle and allow performing single-stage cricopharyngeal
myotomy with pouch remodeling. This may translate into a reduction of anatomical and symptomatic
recurrences and lower reintervention rates.

A complete cricopharyngeal myotomy is the cornerstone of both surgical and endoscopic approaches. From
the flexible endoscopic perspective, the buccopharyngeal fascia represents an important safety landmark.
This thin structure is displaced posteriorly by the diverticulum, and its preservation may guarantee a
complete myotomy without risks. However, it must be kept in mind that the cricopharyngeus is a circular
muscle lacking an external layer of longitudinal muscle and perforation of the buccopharyngeal fascia may
[35]
result in mediastinitis . In real-world practice, it is challenging to identify a precise visual cue confirming
that the myotomy is complete without breaking the fascia and entering the prevertebral space. Often, the
trade-off to minimize the risk of perforation during standard FES is to plan a multi-stage procedure. With
Z-POEM, identification of the buccopharyngeal fascia at the bottom of the pouch remains difficult during
submucosal tunneling, but avoiding the posterior approach may further reduce the risk of perforation .
[36]

Management of ZD requires an interdisciplinary and cooperative approach. Multiple specialists (surgeons,
gastroenterologists, and otolaryngologists) may be involved in the decision-making process to deliver the
best care to the patient. Nowadays, indications for an open surgical approach have become rare. In our
opinion, large ZD (> 3 cm) can be safely treated with endostapling, while smaller ZD can be treated with
FES or Z-POES. Recurrent ZD can be safely treated with either transoral or open approach .
[37]
CONCLUSIONS
Peroral endoscopic myotomy techniques have opened a new era in the management of patients with ZD.
However, appropriate training in advanced operative endoscopy remains critical, and high-quality studies
with long-term and standardized patient-reported outcomes are necessary to validate these promising
clinical findings.

DECLARATIONS
Authors’ contributions
Made substantial contributions to the conception and design of the study and performed data analysis and
interpretation: Siboni S, Bonavina L
Performed data acquisition: Milito P, Scardino A

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
All authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
Not applicable.