Background & Aims: Large Zenker’s diverticula pose technical challenges and higher recurrence risk during Z-POEM. 

Methods:A 59-year-old female with severe dysphagia from a 9-cm Zenker’s diverticulum and underwent modified Z-POEM. Key steps included mucosal incision over the septum, early undersaline immersion, tunnel-free myotomy for efficient progression, extended septotomy into the esophagus, and mucosal flap trimming to avoid food retention. Clips were used for closure.

Results:The procedure was successful with no adverse events. Imaging confirmed full emptying. At 6 months, the patient tolerated a normal diet without symptoms.

Conclusions:This modified technique appears effective for large and complex Zenker’s diverticula.