TUNNEL-ENTRY DEHISCENCE AFTER UNEVENTFUL POEM

Aims:

POEM is an effective and safe treatment of esophageal motor disorders. Although the technique is relatively established and presents a moderate difficulty, some cases may be really challenging due to unusual complications.

Methods:

In a 69 year-old man with Type II Achalasia by high resolution manometry with 24 months of symptoms (Eckardt score: 7) a POEM was performed as the first treatment option without intraprocedural adverse events. Total procedure time 70 min. Start of oral intake at 24 hours and hospital stay (72 hours) developed without complications.

After nine days, the patient came to the emergency department with dysphagia and hematemesis. The previous week he had presented strong coughing.

Results:

Urgent endoscopy revealed a tunnel-entry dehiscence. Some persistent hemoclips were removed and the tunnel was cleaned of clots and food debris. A closing attempt with clips-Polyloop was unsuccessful due to mucosal thickening, tearing the mucosa with the closure of the Polyloop. An attempt to close with an OTSC-clip also failed because of the impossibility of grabbing the tissue. Finally a covered metal stent was placed and due to the remarkable esophageal dilatation, this was fixed with an OTSC-clip just above the fistula. No clinical or radiological findings of mediastinitis or contrast leak were observed. 3 months later the stent was removed without cutting the OTSC-clip. The mucosa presented granulation tissue and the dehiscence had been resolved. After 6 months of the procedure the patient is asymptomatic (Eckardt score: 0, no GERD symptoms)

Conclusions:

Tunel-entry dehiscence is a rare complication of POEM (0.4 in a series of 1680 patients (Zhang et al. Endosc 2016). There is little evidence for the management of these patients.

The placement of a stent is an option and fixing it should be considered due to the dilation of the esophageal lumen inherent to achalasia.