Endoscopic needle-knife diverticulotomy is an established treatment for Zenker’s diverticulum. Zenker peroral endoscopic myotomy (Z-POEM), introduced at our center in 2021, allows creation of a submucosal tunnel and performance of a full septotomy. This technique enables a more complete division of the cricopharyngeal muscle and may therefore result in fewer recurrences and more durable long-term symptom control. The aim of this retrospective study was to evaluate technical feasibility, recurrence and complication rates, and the duration of symptom resolution across different therapeutic approaches, with particular focus on Z-POEM.

Between January 2014 and June 2024, a total of 162 endoscopic interventions for Zenker’s diverticulum were performed at our center, representing one of the larger single-center cohorts reported to date. Procedures included 117 needle-knife diverticulotomies, 35 Z-POEM procedures, and 10 alternative techniques. Patient demographics were recorded (mean age 71 ± 10.35 years, 66% male) as well as diverticulum size (mean 2.71 ± 1.46 cm).

Follow-up was performed retrospectively for patients who had undergone an intervention from 2019 onward. Structured follow-up (telephone and/or endoscopic) was conducted in 2024-2025, yielding evaluable data for 100 procedures (follow-up rate 65%) with a median follow-up of 24 months (IQR 18–45).

Symptom burden was assessed using a standardized score adapted from the Eckardt Score, focusing on the two consistently available domains: dysphagia and regurgitation. Patients were additionally asked to report the duration of subjectively perceived symptom resolution.Outcomes included symptom improvement, complication rates, time to recurrence and recurrence rates.

Median procedure time was comparable between techniques (needle-knife 27 min [6–83] vs. Z-POEM 24.5 min [11–65]). Complications occurred in 8.55% of needle-knife procedures (10/117) and 11.43% of Z-POEM procedures (4/35).

Analysis of clinical outcomes was based on the follow-up cohort with evaluable data (n = 100). Within this cohort, both techniques resulted in marked symptom improvement. Median dysphagia scores improved from 2 to 1 after needle-knife and from 1.5 to 0 after Z-POEM. Regurgitation improved from 1.5 to 0 in both groups. The median duration of symptom resolution was 12 months (IQR 6–26) after needle-knife and 13 months (IQR 12–22.5) after Z-POEM. Among patients experiencing recurrence, symptom-free intervals were 9 months (IQR 6–12) for needle-knife and 6 months (IQR 3–12) for Z-POEM.

Recurrence rates differed substantially between techniques, with 79% recurrence after needle-knife and 43% after Z-POEM. These rates are higher than commonly reported in the literature, most likely reflecting a follow-up bias, as patients tended to return primarily in the case of symptomatic recurrence and no scheduled endoscopic reassessment was performed. In multivariate logistic regression, Z-POEM was independently associated with significantly lower odds of recurrence compared with needle-knife (OR 0.197, 95% CI 0.063–0.587, p = 0.004).

Z-POEM proved to be an effective and safe treatment option for Zenker’s diverticulum and was associated with significantly lower recurrence rates compared with needle-knife diverticulotomy. Both techniques resulted in meaningful symptom improvement, but Z-POEM achieved complete resolution more consistently and showed an independent association with reduced recurrence in multivariate analysis. These findings underscore the clinical relevance of a complete septotomy and support Z-POEM as a durable and effective endoscopic treatment option for Zenker’s diverticulum.