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A 71-year-old man was referred for a symptomatic Zenkerʼs diverticulum. The patient had undergone a stapled diverticulotomy 7 years ago. A barium esophagram revealed a 3-cm Zenker’s diverticulum with evidence of staples (▶Fig. 1 a). The decision was made to perform a peroral endoscopic myotomy of Zenker’s diverticulum (Z-POEM). A submucosal injection was performed with the intention of creating a bleb above the septum using a combination of normal saline and methylene blue. However, the bleb could not be created because of submucosal scarring and fibrosis (▶Fig. 1 b, ▶Video 1). A mucosal incision was made with a triangle-tip knife (KD 640 L; Olympus, Center Valley, Pennsylvania, USA) using EndoCut Q current, effect 3, and staples were seen through the incision. A clear submucosal layer could not be exposed because of extensive scarring and fibrosis, and thus tunneling was not possible. The decision was made to perform a standard septotomy (myotomy), which was started with a triangle-tip knife and then continued with a scissor-type endoscopic submucosal dissection (ESD) knife (SB knife, Olympus). A standard septotomy of 1.5 cmwas performed using EndoCut Q current, effect 3, after which a clear submucosal layer was observed (▶Fig. 1 c, d). The procedure was continued using the Z-POEM technique to ensure complete exposure and dissection of the septum. Tunneling was performed along the esophageal and diverticular sides of the septum using a triangle-tip knife and spray coagulation mode, effect 2. Once the cricopharyngeal muscle septum was completely exposed, it was dissected for 2 cm down to the bottom of the diverticulum with a scissor-type ESD knife and EndoCut Q current (▶Fig. 1 e). The mucosal incision was closed using throughthe-scope clips (MicroTech, Ann Arbor, Michigan, USA) (▶Fig. 1 f). The patient was admitted overnight. An esophagram performed the next day showed no leakage, and the patient was discharged on a soft diet. At follow-up 3months post-procedure, the patient had complete resolution of the symptoms with no residual symptoms while taking a full diet. The standard approach to Z-POEM starts with a mucosal incision, submucosal tunneling, septum division (septal myotomy), and mucosal closure [1]. On the other hand, in patients with prior such E-Videos

Hybrid endoscopic approach for submucosal tunneling septum division for Zenkerʼs diverticulum