The results identify MEDCO as superior in comparison with ESED and OTA concerning the treatment for Zenker's diverticulum especially in terms of excellent long-term functional results and a low morbidity and mortality. The short operation time qualifies MEDCO as specifically suitable for the treatment of the characteristic patient cohort with Zenker's diverticulum, namely the elderly, whereas OTA should be reserved for cases with sophisticated or impossible endoscopic exposure of the pouch. The occurrence of perioperative fever can be managed with a systemic antibiotic and antipyretic medication. Although a mediastinitis as major complication is a rare event, the early introduction of its diagnosis with CT scans and consecutive therapy including thoracotomies can be lifesaving.