POEM for Zenker’s diverticulum (Z-POEM): Technical advances, challenges and complications – a narrative review

• Z-POEM achieves >90 % clinical success with durable symptom relief. • Technical variations (NiZ-POEM, tunnel-free) broaden clinical applicability. • Safety profile is favorable, with low rates of bleeding or perforation. • Z-POEM compares favorably to flexible septotomy in efficacy and safety. • Cost-effectiveness analyses support Z-POEM in specialized centers. Zenker's Diverticulum (ZD) is a pharyngoesophageal pulsion diverticulum traditionally managed with open surgical or endoscopic (rigid and flexible) techniques. Zenker’s Peroral Endoscopic Myotomy (Z-POEM) has recently emerged as a minimally invasive alternative demonstrating promising efficacy and safety. This narrative review aims to synthesize current evidence regarding the technical evolution of Z-POEM, its indications, procedural nuances, long-term outcomes, cost-effectiveness, and future directions. A structured narrative review was conducted in accordance with SANRA guidelines to assess the technical modifications, clinical outcomes, and complications of Zenker’s Per-Oral Endoscopic Myotomy (Z-POEM). Relevant literature published between January 2016 and September 2025 was systematically searched across PubMed, Scopus, and EMBASE, supplemented by manual citation tracing. Eligible studies included clinical trials, cohorts, observational reports, and technical notes focusing on Z-POEM or its variants. Data extraction and synthesis were performed independently by two reviewers, with findings organized into thematic domains comprising procedural techniques, efficacy, safety, adverse events, recurrence, and follow-up. Proper patient selection is critical for technical success. Factors such as diverticulum size, symptom severity, and anatomical features guide the optimal technique. Long-term studies report sustained clinical success exceeding 85% over 30‒40 months. Repeat Z-POEM procedures have shown high efficacy in managing recurrence. Comparative data indicate Z-POEM achieves superior clinical outcomes compared with flexible endoscopic septotomy, with comparable safety and procedure times. Z-POEM demonstrates high safety and efficacy, though long-term durability may favor Z-POEM in larger or fibrotic diverticula. Further research should focus on cost-effectiveness, technique standardization, and long-term comparative outcomes to refine patient selection criteria and consolidate Z-POEM as a first-line therapy for ZD.