Post-peroral endoscopic myotomy dehiscence treated with an esophageal fully covered self-expandable metal stent

Peroral endoscopic myotomy (POEM) is an effective and safe technique for treating esophageal achalasia [1] [2]. Adverse events related to POEM, although uncommon, may present a diagnostic and therapeutic challenge [2] [3]. Fully covered self-expandable metal stents (FCSEMSs) have been successfully used in several complications of esophageal procedures, such as perforation, fistula, and leakage [4] [5].

A 59-year-old man presented with intermittent dysphagia to solids and fever. He had undergone POEM 6 days before for symptomatic type III achalasia (Eckardt's score of 8) with a posterior incision. Intravenous prophylactic antibiotics were administered before and after the procedure. Upper endoscopy (GIF-Q165; Olympus, Tokyo, Japan) revealed dehiscence of the previously closed mucosal incision, with purulent material located inside the tunnel ([Fig. 1, ] [Fig. 2]). Gentamicin was flushed through the tunnel and intravenous antibiotics were started (piperacillin/tazobactam and metronidazole). A 23 × 105-mm FCSEMS (Wallflex Esophageal Stent; Boston Scientific, Marlborough, Massachusetts, USA) was placed under direct endoscopic visualization ([Fig. 3]) and radioscopic control ([Video 1]). The stent was repositioned using a rat tooth grasping forceps (FG-48L-1; Olympus, Tokyo, Japan) and then fixed with a through-the-scope clip (Resolution 360 Clip; Boston Scientific) and an over-the-scope clip (OTSC System Set, 11/6 mm, type t; Ovesco Endoscopy AG, Tuebingen, Germany). A thoracic computed tomography excluded mediastinitis, periesophageal fluid collections, or fistula. Antibiotics were continued for 14 days in association with fluconazole for 7 days. Afterwards, the patient showed clinical improvement. An upper endoscopy was performed 3 weeks weeks after stent deployment. The esophageal stent was removed using a rat tooth grasping forceps (FG-48L-1, Olympus), and complete closure of the former dehiscence was observed ( [Fig.4]). There was no difficulty passing the endoscope through the esophagogastric junction.

Fig. 1 Upper endoscopy after peroral endoscopic myotomy showed dehiscence of the previously closed mucosal incision.

Fig. 2 Endoscopic view of the inside of the tunnel containing purulent material.

Fig. 3 Endoscopic view after placement of fully covered self-expandable esophageal metal stent.

Video 1 An infected dehiscence of the mucosal incision after peroral endoscopic myotomy was closed using a fully covered self-expandable esophageal metal stent placed for 3 weeks.

Fig. 4 Endoscopic evaluation after stent removal showing closure of the dehiscence.

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Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Inoue H, Minami H, Kobayashi Y. et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 2010; 42: 265-271
• 2 Zhang XC, Li QL, Xu MD. et al. Major perioperative adverse events of peroral endoscopic myotomy: a systematic 5-year analysis. Endoscopy 2016; 48: 967-978
• 3 Nabi Z, Reddy DN, Ramchandani M. Adverse events during and after per-oral endoscopic myotomy: prevention, diagnosis, and management. Gastrointest Endosc 2018; 87: 4-17
• 4 Fernández A, González-Carrera V, González-Portela C. et al. Fully covered metal stents for the treatment of leaks after gastric and esophageal surgery. Rev Esp Enferm Dig 2015; 107: 608-613
• 5 van Boeckel PG, Sijbring A, Vleggaar FP. et al. Systematic review: temporary stent placement for benign rupture or anastomotic leak of the oesophagus. Aliment Pharmacol Ther 2011; 33: 1292-1301

Publication History

Article published online:
08 October 2020