Marsupialisation of a tunnel flap for a false oesophageal lumen post peroral endoscopic myotomy

A 68-year-old woman with type 2 achalasia, chronic oesophageal stasis, a thickened mucosal layer, and an Eckardt score of 8 underwent an uncomplicated peroral endoscopic myotomy (POEM; [Fig. 1]). One-month post-POEM, she developed recurrent dysphagia, regurgitation and aspiration. Repeat gastroscopy revealed dehiscence of the oesophageal mucosotomy (tunnel orifice) and formation of a long false lumen ([Video 1]). This was consistent with the original submucosal tunnel, with its wall being a mucosal flap and a healed post-myotomy muscularis propria layer.

Fig. 1 Achalasia changes with food contamination and aperistalsis in a. Peroral endoscopic myotomy performed in b, with clip closure following the POEM procedure in c. POEM, peroral endoscopic myotomy.

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Mucosotomy dehiscence is found 1 month following a POEM procedure. Marsupialisation of the tunnel mucosal flap is performed with resolution of the patient’s symptoms. POEM, peroral endoscopic myotomy.Video 1

A nasojejunal feeding tube was endoscopically placed for feeding ([Fig. 2]). A computed tomographic scan with oral contrast showed minimal passage of contrast into the distal third of the oesophagus and no mediastinal leak ([Fig. 3]). Despite a conservative approach, repeat gastroscopy after a further 4 weeks demonstrated a persistent false lumen, a dilated proximal oesophagus containing food debris and oesophageal candidiasis ([Fig. 4]).

Fig. 2 Formation of a false lumen from the open POEM tract (blue arrow) in a and insertion of a nasojejunal feeding tube in b. POEM, peroral endoscopic myotomy.

Fig. 3 A sagittal CT scan with oral contrast showing no mediastinal leak with a dilated oesophagus (red arrow). CT, computed tomography.

Fig. 4 A false lumen with a Jagwire passing into the open POEM tract in a and insertion of the Jagwire through the POEM tract into the stomach in b. POEM, peroral endoscopic myotomy.

Three months post-POEM procedure, we proceeded with endoscopic marsupialisation of the false lumen. The tunnel was completely epithelialised. There was a small fistula back into the oesophagus at the level of the gastro-oesophageal junction (GOJ). A 0.035-inch Jagwire was placed into the false lumen, through the distal opening and into the stomach ([Fig. 5]). An endoscopic knife was used to dissect the mucosal flap, using the wire as a guide down to the GOJ. Redundant mucosal tissue at the site of the incision was then resected with the EMR technique using a 10 mm hot snare. Repeat gastroscopy 7 months post-POEM showed a healthy appearing scar without evidence of a false lumen. The lower oesophageal sphincter opened easily ([Video 1]). Reassuringly, the patient’s symptoms had resolved following this, with an Eckardt score of 0.

Fig. 5 Marsupialisation of the tunnel flap in a and histology of the resection mucosal flap in b, showing dense fibrosis in submucosa with no definite muscularis propria seen.

Dehiscence of a submucosal tunnel mucosotomy site leading to a false lumen is a rare complication of POEM [1] [2] [3]. Symptom recurrence post-POEM warrants further endoscopic evaluation. Herein, we have demonstrated a novel technique of guidewire-assisted marsupialisation and eliminated the false lumen and the associated symptoms.

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Contributorsʼ Statement

Hasib Ahmadzai: Conceptualization, Software, Writing – original draft, Writing – review & editing. Clarence Kerrison: Writing – review & editing. Jun Young Kim: Writing – review & editing. Brian Lam: Writing – review & editing. Yong Sul Kim: Writing – review & editing. Sunil Gupta: Supervision, Writing – original draft, Writing – review & editing. Michael J. Bourke: Conceptualization, Formal analysis, Supervision, Writing – original draft, Writing – review & editing.

Conflict of Interest

Professor Michael J. Bourke: Research Support: Olympus, Cook Medical, Boston Scientific. Dr Sunil Gupta is a junior co-editor of the Endoscopy Journal. The remaining authors have no conflicts of interest to disclose.

• References

• 1 Sidhu M, Tate D, Bourke MJ. 1147 Resolution of a Persistent Mucosal Defect After Peroral Endoscopic Myotomy (POEM) With Clip Closure. Gastrointest Endosc 2022; 85: AB153
• 2 Nabi Z, Reddy N, Ramchandani M. Adverse events during and after per-oral endoscopic myotomy: prevention, diagnosis, and management. Gastrointest Endosc 2018; 87: 4-17
• 3 Bhandari S, Parekh D, Bhandari S. Endoscopic management of mucosal incision site dehiscence following peroral endoscopic myotomy. Endosc Int Open 2022; 10: E1307-E1308

Publication History

Article published online:
15 January 2026