# Leak Following Zenker’s Peroral Endoscopic Myotomy (Z-POEM): Non-operative Management Strategy of a Large Undrained Submucosal Cavity

## TL;DR

A non-operative treatment successfully managed a large undrained cavity following a Z-POEM procedure for Zenker’s diverticulum.

## Contribution

This case demonstrates a novel non-operative management strategy for contained leaks after Z-POEM using endoscopic mucosal dissection.

## Key findings

- A contained undrained cavity following Z-POEM can be managed non-operatively with endoscopic dissection.
- Early recognition and drainage of the cavity facilitated healing and re-epithelization of the esophageal lumen.
- Short-interval follow-up is crucial after Z-POEM for small diverticula due to potential closure failure from tension.

## Abstract

Zenker’s peroral endoscopic myotomy (Z-POEM) is a safe and effective endoscopic therapy for Zenker's diverticulum. The most common serious complication was reported to be perforation, which can often be treated non-operatively, although the optimal management strategy has not been established. Here, we present a case of a 72-year-old female patient who had a leak following Z-POEM to treat a 1.5-cm, small Zenker’s diverticulum with concomitant hypopharyngeal stricture. Tension on a mucosal closure caused mucosal dehiscence, which communicated to a deep submucosal tunnel and led to an 8-cm contained undrained cavity posterior to the esophagus as demonstrated by computed tomography. Once it was recognized that the deep cavity was contained and granulating without clinical signs of mediastinitis, endoscopic dissection of the mucosa over the deep, undrained cavity was performed to provide continuous, optimal drainage, thus significantly facilitating the healing process with granulation formation and re-epithelization of the esophageal lumen. A contained leak after Z-POEM without signs of mediastinitis can be treated conservatively. It is important to have short-interval follow-up after Z-POEM to treat small Zenker’s diverticula, as the closure in such cases can fail early due to tension.