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Background: Treatment of Zenker's diverticulum has evolved from open surgery to endoscopic techniques, including flexible and rigid endoscopic septotomy, and more recently, peroral endoscopic myotomy (Z-POEM). This study compared the effectiveness of flexible and rigid endoscopic septotomy with that of Z-POEM., Methods: Consecutive patients who underwent endoscopic septotomy (flexible/rigid) or Z-POEM for Zenker's diverticulum between 1/2016 and 9/2019 were included. Primary outcomes were clinical success (decrease in Dakkak and Bennett dysphagia score to ≤ 1), clinical failure, and clinical recurrence. Secondary outcomes included technical success and rate/severity of adverse events., Results: 245 patients (110 females, mean age 72.63 years, standard deviation [SD] 12.37 years) from 12 centers were included. Z-POEM was the most common management modality (n = 119), followed by flexible (n = 86) and rigid (n = 40) endoscopic septotomy. Clinical success was 92.7 % for Z-POEM, 89.2 % for rigid septotomy, and 86.7 % for flexible septotomy ( P  = 0.26). Symptoms recurred in 24 patients (15 Z-POEM during a mean follow-up of 282.04 [SD 300.48] days, 6 flexible, 3 rigid [ P  = 0.47]). Adverse events occurred in 30.0 % rigid septotomy patients, 16.8 % Z-POEM patients, and 2.3 % flexible septotomy patients ( P  < 0.05)., Conclusions: There was no difference in outcomes between the three treatment approaches for symptomatic Zenker's diverticulum. Rigid endoscopic septotomy was associated with the highest rate of complications, while flexible endoscopic septotomy appeared to be the safest. Recurrence following Z-POEM was similar to flexible and rigid endoscopic septotomy. Prospective studies with long-term follow-up are required., Competing Interests: M.A. Khashab is a consultant for Boston Scientific, Olympus, Medtronic, GI Supply, and Triton. B.J. Elmunzer is a consultant for Takeda Pharmaceuticals. V. Kumbhari is a consultant for Apollo Endosurgery, Boston Scientific, Medtronic, FuijFilm, Pentax Medical, ReShape Lifesciences, and Obalon, and has received research support from ERBE and Apollo Endosurgery. D.J. Yang is a consultant for Boston Scientific, Lumendi, and Steris. G.G. Ginsberg is a consultant for Olympus Inc. and Boston Scientific. M. Ujiki is a consultant for Olympus, Boston Scientific, and Cook, and receives grant funding from Medtronic; he is also a speaker for Medtronic and Gore, and receives fellowship funding from Boston Scientific. J.M. Nieto is a consultant for Boston Scientific and ERBE. S. Andrawes is a consultant for Olympus. The remaining authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Background: Zenker's peroral endoscopic myotomy (Z-POEM) is a novel procedure for the management of symptomatic Zenker's diverticulum. This study aims to report the technical feasibility and outcomes of Z-POEM in the management of Zenker's diverticulum after prior failed interventions., Methods: Patients with persistent or recurrent symptoms after prior endoscopic and/or surgical intervention for Zenker's diverticulum were retrospectively included. The primary outcome was clinical success, defined as complete or near complete resolution of dysphagia (dysphagia score of 0 or 1) without the need for repeat endoscopic or surgical intervention during follow-up., Results: Z-POEM was technically successful in 30/32 patients (93.8 %). Clinical success was achieved in 29/30 patients (96.7 %), and Z-POEM significantly reduced the median (interquartile range [IQR]) dysphagia score of patients from 2 (1 - 2) to 0 (0) (P < 0.001) over a median duration of follow up of 166 days (IQR 39 - 566). Four patients (12.5 %) had adverse events (two inadvertent mucosotomies and two leaks found on post-procedural esophagrams)., Conclusion: Z-POEM is feasible, safe, and effective in the majority of patients with recurrent symptoms after prior surgical or endoscopic interventions., Competing Interests: J. Nieto is a consultant and speaker for Boston Scientific and ERBE; P. Desai is a trainer for Olympus and ERBE India; G.G. Ginsberg is a consultant for Olympus and Cook Medical; M. Saumoy is a consultant for Boston Scientific, Olympus, and Takeda pharmaceuticals; M. Ujiki is a consultant for Boston Scientific, Olympus, Coviden LP, and Apollo Endosurgery; M.A. Khashab is a consultant for Boston Scientific, Olympus, and Medtronic. The remaining authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Competing Interests: Drs. Carr-Locke and Sharaiha are consultants for Boston Scientific, Olympus, and Medtronic.

Competing Interests: Dr. Kahaleh has received research and training grants from BSC, Cook, Olympus, Gore, Emcision, and Pinnacle., (© Georg Thieme Verlag KG Stuttgart · New York.)

Competing Interests: Dr. R. Sharaiha is a consultant for Boston Scientific, Apollo and Olympus., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: Gastroparesis is a difficult-to-treat motility disorder with a poor response to medical therapy. Gastric peroral endoscopic pyloromyotomy (G-POEM) has been offered as a novel therapy in the treatment of refractory gastroparesis. We present a multicenter case series of our experience with G-POEM., Methods: This is an international multicenter case series of patients who underwent G-POEM for the treatment of gastroparesis. The severity of gastroparesis was assessed by delayed gastric emptying scintigraphy (GES) and an elevated gastroparesis cardinal symptoms index (GCSI). Patients then underwent G-POEM using the submucosal tunneling technique. The primary endpoint was improvement in the GCSI score and improvement in gastric emptying on repeat scintigraphy. Secondary endpoints were technical success, complication rate, procedure duration, and length of hospital stay post-procedure., Results: G-POEM was technically successful in all 33 patients. Symptomatic improvement was seen in 28/33 patients (85 %), with a decrease in symptom score by GCSI from 3.3 to 0.8 at follow-up ( P  < 0.001). The mean procedure duration was 77.6 minutes (37 - 255 minutes). Mean GES improved significantly from 222.4 minutes to 143.16 minutes ( P <  0.001). Complications were minimal and included bleeding (n = 1) and an ulcer (n = 1) treated conservatively. The mean length of hospital stay post-procedure was 5.4 days (1 - 14 days). The mean follow-up duration was 11.5 months (2 - 31 months)., Conclusion: G-POEM is a technically feasible, safe, and successful procedure for the treatment of refractory gastroparesis. A further multicenter comparative study should be performed to compare this technique to laparoscopic pyloromyotomy., Competing Interests: Michel Kahaleh has received grant support from Boston Scientific, Fujinon, EMcison, Xlumena Inc., W.L. Gore, MaunaKea, Apollo Endosurgery, Cook Endoscopy, ASPIRE Bariatrics, GI Dynamics, NinePoint Medical, Merit Medical, Olympus, and MI Tech. He is a consultant for Boston Scientific, Xlumena Inc., Concordia Laboratories Inc, ABBvie, and MaunaKea Tech. Amy Tyberg is a consultant for EndoGastric Solutions. None of the other authors have conflicts of interest to report., (© Georg Thieme Verlag KG Stuttgart · New York.)

Competing Interests: Dr. Sharaiha is a consultant for Boston Scientific Corp. and Apollo Endosurgery. Dr. Locke is a Consultant for Boston Scientific Corp. and has received royalty payments from Steris Corp. and Telemed Systems.

Competing Interests: Reem Z. Sharaiha is a consultant for Boston Scientific and Apollo Endosurgery.

Competing Interests: Reem Z. Sharaiha is a consultant for Boston Scientific and Apollo Endosurgery.

Competing Interests: Michel Kahaleh MD has received grant support from Boston Scientific, Fujinon, EMcison, Xlumena Inc., W.L. Gore, MaunaKea, Apollo Endosurgery, Cook Endoscopy, ASPIRE Bariatrics, GI Dynamics, NinePoint Medical, Merit Medical, Olympus and MI Tech. He is a consultant for Boston Scientific, Xlumena Inc., Concordia Laboratories Inc, ABBvie, and MaunaKea Tech.All other authors have no conflicts of interest to report.

Competing Interests: Michel Kahaleh MD: has received grant support from Boston Scientific, Fujinon, EMcison, Xlumena Inc., W.L. Gore, MaunaKea, Apollo Endosurgery, Cook Endoscopy, ASPIRE Bariatrics, GI Dynamics, NinePoint Medical, Merit Medical, Olympus and MI Tech. He is a consultant for Boston Scientific, Xlumena Inc., Concordia Laboratories Inc, ABBvie, and MaunaKea Tech.

Competing Interests: Competing interests: Michel Kahaleh MD: has received grant support from Boston Scientific, Fujinon, EMcison, Xlumena Inc., W.L. Gore, MaunaKea, Apollo Endosurgery, Cook Endoscopy, ASPIRE Bariatrics, GI Dynamics, NinePoint Medical, Merit Medical, Olympus and MI Tech. He is a consultant for Boston Scientific, Xlumena Inc., Concordia Laboratories Inc, ABBvie, and MaunaKea Tech.All other authors have no conflicts of interest to report.

Competing Interests: Competing interests: M. Kahaleh has received grants from Boston Scientific, Olympus, Cook Medical and Gore Medical.

Competing Interests: Competing interests: M. Kahaleh has received research grants from BSC, Xlumena, Cook, Olympus, Merit Endotek, Aspire Bariatrics, GI Dynamics, Apollo, Fuji, Pentax, Emcision, Concordia, MI Tech, Maunakea Tech, Ninepoint Medical, W. L. Gore, and the American Society for Gastrointestinal Endoscopy (ASGE).

Competing Interests: Competing interests: Michel Kahaleh MD: has received grant support from Boston Scientific, Fujinon, EMcison, Xlumena Inc., W.L. Gore, MaunaKea, Apollo Endosurgery, Cook Endoscopy, ASPIRE Bariatrics, GI Dynamics, NinePoint Medical, Merit Medical, Olympus and MI Tech. He is a consultant for Boston Scientific, Xlumena Inc., Concordia Laboratories Inc, ABBvie, and MaunaKea Tech. All other authors have no conflicts of interest to report.

Competing Interests: Competing interests: Dr. Kahaleh has received research support from Pinnacle, EMcision, and Boston Scientific Corp. He is a consultant for Xlumena, Concordia lab, and Boston Scientific Corp.

Competing Interests: Competing interests: None

Competing Interests: Competing interests: Reem Z. Sharaiha is a consultant for Apollo endosurgery.