T-shape mucosal incision as an alternative for Z-POEM

Abstract Text A 54-year-old man with symptomatic recurrence after classical endoscopic diverticulotomy was proposed for Z-POEM. Z-POEM was started with mucosal incision directly over the septum. Two submucosal tunnels were made on each side of the cricopharyngeal muscle, with subsequent myotomy. At the end, two T-shaped mucosal incisions were made consisting of longitudinal cranio-caudal incisions on both remaining mucosal flaps. Z-POEM uses the third space to create a tunnel to facilitate complete visualization of the septum and cutting it entirely. With T-shape mucosal incisions, the mucosal flap may be incised up to the base of the diverticulum. The goal is to reduce the mucosal flap and residual pouch, diminishing the theoretical risk of recurrence.