endoscopic trans-esophageal retrograde drainage tandem with endoscopic closure for management of esophageal leak after per-oral endoscopic myotomy for Zenker's diverticulum. These are our disclosures. An 81-year-old male presented with a one-year history of dysphagia and hoarseness of voice secondary to Zenker's diverticulum and cricopharyngeal muscle hypertrophy. Upper endoscopy showed a small Zenker's diverticulum with a tight cricopharyngeal bar and narrowed esophageal lumen opposite to the cricopharyngeal bar. Z poem was performed with a three centimeter myotomy and seven ligatures were placed resulting in the complete closure of the defect. His recovery was uneventful post-operatively and he was discharged home on the same day with a five-day course of antibiotics. One day post-procedure he developed extensive subcutaneous emphysema secondary to leak from premature opening of the entry closure. The leak was closed with extract system and fully covered esophageal metal stent. Subsequent esophagogram confirmed no leak following stent removal and he was discharged home. One week later he presented with cough without dysphagia. Repeat endoscopy showed reopening of the fistula with an eight centimeter cavity extending into the posterior mediastinum. After a thorough lavage the fistula was closed with extract system and covered with a fully covered esophageal metal stent. Post-procedural esophagogram demonstrated no leak but stent migrated subsequently. Five endoscopies were performed afterwards for stent revisions but sealing of the leak was not successful. With his age and comorbidities surgical intervention was avoided. Endoscopic ultrasound guided drainage was not feasible due to the upper esophageal sphincter stenosis and the cavity being wide but thin. Therefore a decision was made for endoscopic guided direct transesophageal puncture and retrograde placement of the drain to facilitate drainage and healing of the cavity. To perform this procedure we used a bronchoscope, ultrathin and an adult upper endoscope, a 19 gauge fine needle aspiration needle, a long angled 0.025 inch guide wire, a 7 French nasocystic drainage catheter, endoscopic suturing system and a fully covered esophageal metal stent 14 by 62 millimeter. The cavity was irrigated with a slim upper endoscope and suctioned until clear. The cavity measured 7 centimeter. APC was performed ablating the internal lining of the cavity. Using a bronchoscope with larger accessory channel within the cavity, the distal end of the cavity was identified by the trans illumination seen from the esophageal lumen on the side by side slim upper endoscope. A 19 gauge final aspiration needle was advanced to the esophageal lumen from the cavity. A 0.025 inch guide wire was passed through the needle towards the esophageal lumen. The bronchoscope with final aspiration needle was slowly withdrawn keeping the wire in place. To close the fistula, one running suture was placed using the overstitch device. To reinforce the sealing, a 14 by 62 millimeter fully covered esophageal metal stent was placed covering the fistula. The guide wire was then retrieved through the stent and a 7 French nasocystic tube was advanced over the wire through the stent under fluoroscopic guidance into the cavity in retrograde fashion resulting its tip to coil within the cavity. The nasocystic tube was attached to bulb suction to initiate vacuum therapy. 10 days later a CT chest confirmed resolution of the cavity and the leak. The nasocystic tube was removed and the patient was discharged home with gradual advancement of the diet. Two weeks later an endoscopy was performed and the stent was removed. The leak site was well healed. Esophageal leaks with large extra luminal extension often require surgery to debride, clean the fluid cavity and repair of the defect. Surgical intervention are considered highly invasive and surgical closure may not be feasible for leaks in the cervical esophagus. Endoscopy guided direct transesophageal puncture and retrograde mediastinal pigtails drain placement should be considered as an option for drainage of large mediastinal fluid collection after z-poem along with endoscopic closure of the esophageal leak. This technique is highly effective and could potentially avoid a substantial number of repeated interventions, debridement and possibly shorten the length of hospital stay. Novel endoscopic direct transesophageal puncture for retrograde drain placement tandem with endoscopic closure of the leak site was safe and effective for a patient with esophageal leak following z-poem. The technique is minimally invasive and represent a feasible therapeutic alternative to surgery for managing large mediastinal esophageal leaks in the cervical esophagus.

Zenker's diverticulum

cricopharyngeal muscle hypertrophy

per-oral endoscopic myotomy

esophageal leak

endoscopic guided direct transesophageal puncture