Endoscopic suturing for the repair of an obstructing Zanker's diverticulum using a bidirectional endoscopic approach for lumen delineation. Dr. Villa discloses consultantships for Medtronic and Olympus. A 69-year-old male with history of heroin abuse was referred to our interventional gastroenterology clinic for evaluation for dysphagia with immediate solid and liquid diet regurgitation endorsed by his skilled nursing facility care team. He had been discharged to the skilled nursing facility after prolonged intensive care as a result of respiratory failure sustained in the setting of heroin overdose and COVID pneumonia, ultimately requiring tracheostomy and percutaneous gastrostomy to proceed. Computed tomography was obtained demonstrating proximal esophageal dilatation with an air fluid level with incomplete assessment of the mid and distal esophagus. Subtle intolerance to contrast precluded a thorough oral contrasted CT. An operandoscopy was then performed to evaluate his dysphagia and was notable for a blind esophageal pouch without any discernible esophageal lumen. Contrast was then injected through the channel of the scope, but no anterograde passage of the contrast material seen on fluoroscopy nor any opacification of the mid or distal esophagus were noted. Because of the suspicion for esophageal discontinuity, the decision was made to pursue retrograde endoscopy through the gastrocutaneous fistula at the gastrostomy tube site. The pediatric gastroscope was inserted through the fistula and advanced retrograde to the proximal esophagus where the anterograde adult gastroscope was used to visualize the passage of the retrograde scope. The retrograde pediatric gastroscope was then passed through the mouth. Using a balloon dilation catheter as a delivery device, a guide wire was advanced through the anterograde adult scope and into the retrograde pediatric scope. This was done to safely advance the anterograde adult gastroscope beyond the level of obstruction and into the stomach. The pediatric retrograde scope was then removed and the anterograde adult scope was withdrawn to the proximal esophagus where it became evident that there was a massive Zanker's diverticulum at the level of the previous obstruction. The singular arrow demarcates the esophageal lumen and the double arrow demarcates the diverticulum. The decision was made to pursue endoscopic diverticular repair with endoscopic suturing. The double-channeled therapeutic gastroscope was inserted with the endoscopic suturing apparatus affixed to the scope tip. Two running sutures with six plications each were used to successfully seal the diverticular pouch and establish esophageal luminal continuity. Contrast was injected through the double-channeled therapeutic gastroscope to confirm successful achievement of esophageal patency. The patient was discharged with a clear liquid diet for two weeks, at which time a repeat upper endoscopy was performed. Repeat upper endoscopy revealed the patent esophageal lumen with easy passage of the therapeutic gastroscope through the re-established esophageal lumen. The patient was advanced to a full liquid diet for one week, followed by advancement to a solid diet, which he is now tolerating without any recurrence of dysphagia or regurgitation. The patient has shown weight gain as a result of improved oral intake and his gastrostomy tube was removed after meeting caloric goals for removal. Endoscopic suturing techniques have shown tremendous promise as primary treatment for a variety of disorders. Application of endosuturing principles offers a non-surgical, non-dissective approach for repair of obstructing esophageal diverticuli. Thank you.

dysphagia

Zanker's diverticulum

heroin abuse

respiratory failure

endoscopic suturing