LAUSR

A 93-year-old woman with known achalasia and remote Heller myotomy presented with chest pain after an episode of emesis. CT showed a dilated esophagus with pneumomediastinum. Upper endoscopy confirmed a large perforation 30 cm from the incisors. A 23-mm 12.5-cm fully covered metal stent was placed. An esophagram demonstrated extravasation of contrast material around the stent (Fig. 1). Upon transfer, repeated upper endoscopy showed a large transmural esophageal tear and extraluminal cavity (Fig. 2). The preexisting esophageal stent was removed, and an attempt was made to close the opening to the cavity with an over-the-scope clip and multiple through-the-scope clips. An esophagram after clip placement demonstrated continued extravasation of contrast material. A new approach was thought to be warranted (Video 1, available online at www.VideoGIE.org). Two 7F 15-cm double-pigtail plastic stents were placed into the cavity with their distal ends extending into the stomach. Two side-by-side 23-mm 15.5-cm partially covered metal