Closure of a giant gastroesophageal mucosal tear after peroral endoscopic myotomy with over-the-scope clip and cyanoacrylate

Insufflation-associated adverse events after peroral endoscopic myotomy (POEM) are frequent although innocuous in most of the patients [1] [2]. However, mucosal injuries could lead to perforation, mediastinitis, or bleeding that could be potentially fatal if not treated appropriately. Hemoclips, over-the-scope (OTS) clips [3], fully covered self-expandable metal stents (FCSEMSs) [4], and cyanoacrylate [5] have been used as alternative treatments for these cases.

A 63-year-old woman with type II achalasia and an Eckardt score of 10 underwent a POEM procedure without complications. The patient was discharged at 48 hours on a liquid diet. However, at 72 hours she presented to the emergency department with nausea, hematemesis, tachycardia, retrogastric pain, and respiratory distress. An esophagogastroduodenoscopy (EGD) was performed after 3 hours showing a giant 6-cm esophagogastric tear including the distal esophagus, esophagogastric junction (EGJ), and 2 cm of the gastric side ([Fig. 1]). Mechanical cleaning of clots and debris was performed. A gastrocutaneous-type OTS clip (Ovesco Endoscopy AG, Tübingen, Germany) was placed at the gastric side in retroflexion view and two more in the distal esophagus. Completion of the closure was performed with the injection of 1 cc of undiluted cyanoacrylate (Histoacryl; B-Braun Surgical, Tübingen, Germany) in the distal esophagus in frontal view and 1 cc in retroflexion view at the gastric side ([Fig. 2]). Dehiscence of the entry site was observed and closure completed with hemostatic clips (Boston Scientific, Marlborough, Massachusetts, USA).

Fig. 1 a Beginning of esophageal tear at distal esophagus. b Distal component including esophagogastric junction and gastric side.

Fig. 2 a Over-the-scope (OTS) clip placement in retroflexion view. b Cyanoacrylate placement at remanent mucosal defect. c OTS clip placement in frontal view at distal esophagus. d Complementary cyanoacrylate application in distal esophagus mucosal tear.

The patient was admitted to the intensive care unit (ICU) for observation and managed conservatively. Resolution of the systemic inflammatory response syndrome was observed at 48 hours after treatment. A second EGD was performed on the third day showing adequate closure, and a water-soluble contrast esophagram on the fifth day showed adequate passage of contrast without leakage and the OTS clips in place. A liquid diet was started, and the patient discharged on the seventh day. Diet was progressed to a soft and then normal diet in the next 2 weeks.

A follow-up EGD was performed at 8 weeks showing a complete repair of the mucosal tear with the OTS clip in place and clinically an Eckardt score of 0 ([Fig. 3], [Video 1]).

Fig. 3 a Water-soluble contrast esophagram showing OTS clips in adequate place and no leakage on fifth day after placement. b, c OTS clips in place after 8 weeks of closure.

Video 1 Closure of a giant gastroesophageal mucosal tear after peroral endoscopic myotomy with over-the-scope clip and cyanoacrylate.

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Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 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
• 2 Haito-Chavez Y, Inoue H, Beard KW. et al. Comprehensive analysis of adverse events associated with per oral endoscopic myotomy in 1826 patients: an international multicenter study. Am J Gastroenterol 2017; 112: 1267-1276
• 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 Flor de Lima M, Nunes N, Chálim C. et al. Post-peroral endoscopic myotomy dehiscence treated with an esophageal fully covered self-expandable metal stent. Endoscopy 2021; 53: E293-E294
• 5 Hernandez M, Solórzano P, Blanco G. et al. Use of cyanoacrylate to treat mucosal perforation during or after peroral endoscopic myotomy. Endoscopy 2016; 48: E330-E331

Publication History

Article published online:
11 April 2023