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Introduction Zenker’s diverticulum is the most common diverticula of the esophagus. Although small diverticula can be asymptomatic, larger diverticula can cause substantial symptoms such as dysphagia with resultant weight loss and malnutrition, regurgitation, hoarseness, cough, choking and aspiration pneumonia. Flexible endoscopic septotomy (FES) and peroral endoscopic myotomy (Z-POEM) are commonly used treatments for Zenker’s diverticulum. Studies comparing their efficacy and safety have reported conflicting results. We conducted a meta-analysis to compare FES with Z-POEM for the management of Zenker’s diverticula.Methods We reviewed several databases including PubMed, Embase (Embase.com, Elsevier), Web of Science Core Collection, and the Cochrane Database of Systematic Reviews (Cochrane Library, Wiley) from inception to April 28, 2024 to identify studies that compared FES with Z-POEM in patients with Zenker’s diverticulum. Our outcomes of interest were clinical success, technical success, adverse events, recurrence of symptoms and mean procedure duration. We calculated pooled risk ratio (RR) with 95% confidence intervals (CI) for categorical variables and mean difference (MD) with 95% CI for continuous variables. We used a random effect model to analyze the data. Heterogeneity was assessed using the I 2 statistic. We used the Methodological Index for Nonrandomized Studies (MINORS) criteria for assessment of the quality of observational studies.Results We included eight studies with 464 patients. We found that the rate of clinical success was significantly higher in Z-POEM group compared to FES group, RR (95% CI): 1.07 (1.00, 1.15), I2= 0% ( figure 1). We found no significant difference in rate of adverse events, RR (95% CI): 1.07 (0.33, 3.47), I2= 68% and recurrence, RR (95% CI): 0.77 (0.41, 1.46), I2= 15% between groups. There was no significant difference in rate of technical success between groups, RR (95% CI): 1.00 (0.96, 1.03), I2= 0%. We also found no significant difference in procedure duration between groups, MD (95% CI): 5.69 (-0.07, 11.46).Conclusions Our meta-analysis demonstrated comparable outcomes between Z-POEM and FES in patients with Zenker’s diverticulum except for the outcome of clinical success which was higher in Z-POEM group.Abstract O72 Figure 1Comparison of clinical success between groups