ENDOSCOPIC TREATMENT OF INTRAMURAL FISTULA E MUCOSAL TEAR OCCURRED AFTER PERORAL ENDOSCOPIC MYOTOMY (POEM)

Aims:

POEM is a safe procedure for the treatment of esophageal motility disorders. A correct closure of the esophageal mucosal incision (mucosotomy) and the integrity of the mucosal flap are crucial for the safety of the procedure, in order to prevent esophageal leakages and infections.

Methods:

We present the case of a POEM complicated by the dehiscence of the mucosotomy, multiple tears of the mucosal flap and the creation of intramural esophageal fistula.

A 72-year-old woman presented with severe dysphagia, regurgitation, pain and weight loss. A type III achalasia was diagnosed and a POEM was performed. Perioperative course was uncomplicated.

Two weeks later patient presented with chest pain and recurrent dysphagia for solids.

An EGD showed a dehiscence of the mucosotomy with multiple openings on the mucosal flap, putting in communication the real esophageal lumen with the submucosal tunnel created during the POEM. No full thickness perforations were seen.

CT-scan did not reveal any leakage or periesophageal collection.

In order to avoid the entrapment of food into this false lumen, we decided to entirely cut the mucosal flap.

A distal and a triangle-tip knife with Endocut mode was used for the mucosal incision.

Results:

The procedure was relatively easy, quick, and uncomplicated.

CT-scan and Gastrografin swallow showed no leakages or complications, and the patient started oral feeding since the second post-operative day.

One year later the patient is in relatively good conditions, without dysphagia.

Conclusions:

Dehiscence of mucosotomy rarely complicates POEM, but can be theoretically responsible of mediastinitis and infections.

The incision of the mucosal flap above the esophageal false lumen, a kind of fistulotomy, guaranteed a quick and easy solution for an unusual clinical problem.