Mucosal leak after peroral endoscopic myotomy: what to do?

Peroral endoscopic myotomy (POEM) is becoming the first-line therapy for achalasia. It is a safe and minimally invasive treatment with a low rate of adverse events (AEs). The integrity of the mucosal flap at the end of POEM and adequate closure of the incision site are essential to avoiding AEs [1] [2] [3] [4] [5]. Postoperative AEs (e.g. leaks, late mucosal perforations) are considered difficult to diagnose and manage [4].

An 84-year-old man with type II achalasia underwent POEM, using an anterior approach ([Video 1]). The following day, an esophageal X-ray with water-soluble contrast showed a double-lumen appearance ([Fig. 1]). An esophagogastroduodenoscopy revealed leakage distal to a dehiscent mucosotomy ([Fig. 2]). After an unsuccessful attempt to close the leak with endoclips, we placed a fully covered metal stent (ESP1808F; TaeWoong Medical, Gimpo, South Korea) as described in the literature [1] [2]. A subsequent computed tomography scan showed no collections or abscesses but residual contrast in the false lumen ([Fig. 3] a, b). Through a literature search, we found the paper by Familiari et al. [3], and 2 days after stent placement we removed the endoprosthesis. Using a Triangle-Tip J Knife (Olympus, Tokyo, Japan), we incised the mucosal flap with EndoCut current (Erbe Elektromedizin GmbH, Tübingen, Germany), without complications. After 48 hours, the scar showed a regular appearance, esophagogram showed no leakages ([Fig. 4]), and the patient resumed oral feeding without complications. One month later, the mucosa had almost re-epithelialized ([Fig. 5]).

Fig. 1 Esophageal X-ray with water-soluble contrast 24 hours after peroral endoscopic myotomy: esophageal double-lumen appearance.

Fig. 2 Large leakage distal to the dehiscent mucosotomy site.

Fig. 3 Computed tomography. a, b Features after stent placement.

Fig. 4 Esophagogram features after flap mucosotomy.

Fig. 5 Scar features 1 month later.

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Management of a mucosal leak after peroral endoscopic myotomy.Video 1

Unlike other cases [2] [3], our complication was detected early, in an asymptomatic patient (although he had only resumed drinking). Furthermore, the mucosotomy performed 4 days after POEM has proven to be a safe and effective choice to manage this complication.

To date, performing diagnostic examinations to exclude AEs is not required in stable patients [1]. Nevertheless, given that the complication described here was in an asymptomatic patient, it is natural to wonder whether some patients would benefit from performing diagnostic tests before refeeding.

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Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 DeWitt JM, Othman MO, Bapaye A. Do’s and don’ts in esophageal peroral endoscopic myotomy: troubleshooting, managing adverse events, and tips for success. Gastrointest Endosc 2024; 99: 886-894
• 2 Al Taii H, Confer B, Gabbard S. et al. Endoscopic management of an intramural sinus leak after per-oral endoscopic myotomy. ACG Case Rep J 2016; 3: e158
• 3 Familiari P, Landi R, Mangiola F. et al. Endoscopic treatment of intramural fistula and mucosal tear after peroral endoscopic myotomy. Endoscopy 2021; 53: E25-E26
• 4 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
• 5 Ramchandani M, Nabi Z, Inavolu P. et al. Recent advancements and future perspectives of per oral endoscopic myotomy. Clin Gastroenterol Hepatol 2024; 22: 1983-1996.e2

Publication History

Article published online:
08 November 2024