Peroral endoscopic myotomy (POEM) is a safe and effective procedure for patients with
achalasia [1]. Mucosal perforation is an inadvertent complication that is difficult or impossible
to treat with standard clips [2]. Over-the-scope clips, endoluminal suturing devices, and fully covered stents have
been used successfully [3]
[4]. Cyanoacrylate is used as a sealant because of its rapid solidification rate [5]. We report on three patients who were treated successfully with cyanoacrylate following
failure of standard closure.
Case 1: a 26-year-old woman underwent an uncomplicated POEM procedure but presented
nausea, vomiting, and tachycardia 48 hours later. On endoscopy, a wide mucosal injury
was found at the esophagogastric junction and 3 cm below. An attempt at closure was
unsuccessful. Therefore, 2 mL of undiluted cyanoacrylate was applied, and subsequent
esophagram confirmed no leaks. The patient was discharged at 3 days later. Endoscopy
8 months later showed a small scar ([Fig. 1]).
Fig. 1 Endoscopic view showing mucosal injury and treatment after uncomplicated peroral
endoscopic myotomy (POEM). a Tearing at the gastric side of the POEM site, which could not be closed with clips
(retroflexion view). b Mucosal perforation was seen at and 3 cm below the esophagogastric junction. Clip
closure was unsuccessful. c Cyanoacrylate was applied successfully. d Endoscopy 8 months later showed only a small scar at the site.
Case 2: a 51-year-old woman underwent POEM and showed contrast leak into the submucosal
tunnel 24 hours after the procedure. The clips could not be rearranged to close the
defect, and 2 mL of cyanoacrylate was applied successfully. The patient was discharged
48 hours later. Endoscopy confirmed normal mucosal healing ([Video 1]).
Cyanoacrylate use to seal mucosal perforations following peroral endoscopic myotomy.
Conventional closure of the entry site with clips was performed. Esophagram 24 hours
later showed contrast leaking into the submucosal tunnel at the level of the entry
site. Conventional closure of this mucosal defect was unsuccessful. Cyanoacrylate
was applied into the tunnel. No leak was observed on the subsequent esophagram. Endoscopy
1 month later showed adequate healing.
Case 3: a 40-year-old man underwent a difficult POEM procedure owing to the presence
of submucosal fibrosis. He showed tearing of the mucosal entry site, which could not
be closed with clips. Therefore, 3 mL of cyanoacrylate was applied successfully. The
patient was discharged 48 hours later without complications ([Fig. 2]).
Fig. 2 Endoscopic view showing mucosal injury and treatment after difficult peroral endoscopic
myotomy. a Tearing was observed at the entry site, and attempt at closure using clips was unsuccessful.
b Cyanoacrylate was applied over this zone. c Endoscopy 1 month later showed only a small scar at this site.
This is the first report of the use of cyanoacrylate glue to seal mucosal defects
during or after POEM in order to prevent leakage of esophageal contents into the tunnel,
mediastinum or peritoneum. This polymer represents an inexpensive, feasible, and effective
alternative when standard options fail.
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