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Endoscopic management of mucosal incision site dehiscence following
peroral endoscopic myotomy
Peroral endoscopic myotomy (POEM) is
an acclaimed technique for achalasia car-
dia management that is increasingly
being practiced all over the world. Its
known complications are mucosal injury,
esophageal perforation, substantial
bleeding, subcutaneous emphysema,
capnothorax, capnomediastinum, cap-
noperitoneum, and pleural effusion [1,
2]. We report an extremely rare, uncom-
mon POEM complication and its man-
agement with fundamental surgical prin-
ciples.
A 39-year-old male underwent POEM for
primary achalasia cardia. On Day 3 post-
procedure, he developed a fever spike
and retrosternal pain requiring analge-
sics. A plain radiograph of the chest
showed no mediastinal collection (▶Fig.
1). Upper gastrointestinal endoscopy re-
vealed mucosal incision dehiscence
(MID) with seropurulent discharge
(▶Fig. 2). The patient’s submucosal tun-
nel showed signs of inflammation and in-
fection, although the myotomy (muscle
layer) had healed completely. There was
no mediastinal leak. We removed the
clips and washed the submucosal tunnel,
after which the incision was reapproxi-
mated with endoclips. A naso-jejunal
tube was placed for feeding and the pa-
tient was given intravenous antibiotics.
Despite treatment, the patient contin-
ued to have a fever. Endoscopy on Day 6
post-procedure again showed MID with
seropurulent discharge. We decided to
dislodge all the clips and laid open the
submucosal tunnel open by cutting the
whole mucosa with a needle knife
(▶Fig. 3), using a blend endoCUT current
to make the mucosal incision and forced
coagulation to control bleeding when-
ever required (OLYMPUS ESG-100, effect
VidEIO
▶Fig. 1 Plain radiograph of chest show-
ing no mediastinal collection.
▶Fig. 2 Mucosal incision dehiscence with
seropurulent discharge on upper gastro-
intestinal endoscopy.
▶Fig. 3 Dislodgement of clips and open-
ing of mucosa with needle knife on Day 6
post-procedure.
▶Fig. 4 Endoscopic evidence of develop-
ment of granulation tissue with healing
sign on Day 9 post-procedure.
VIDEO
▶Video 1 Complete mucosal healing on Day 17 post-procedure.
Bhandari Suryaprakash et al. Endoscopic management of …Endosc Int Open 2022; 10: E1 307–E1308 | © 2022. The Author(s). E1307
Article published online: 2022-09-14
2, 30 W). The principle was adequate pus
drainage to allow mucosal healing by
secondary intention to prevent mediast-
inal leak due to persistent infection. Sub-
sequent endoscopy on Day 9 post-proce-
dure showed development of granula-
tion tissue with healing signs (▶Fig. 4)
and complete mucosal healing on Day
17 (▶Video 1).
Conclusions
In conclusion, MID is a rare complication
of POEM, which occurred in the present
case most probably because inappropri-
ate clip application prevented ideal clo-
sure. Watertight closure of a mucosal in-
cision is imperative to prevent this com-
plication. Complete mucosectomy (in
the absence of muscle defect) is a safe,
effective option for preventing hazar-
dous mediastinal leaks.
Competing interests
The authors declare that they have no con-
flict of interest.
The authors
Suryaprakash Bhandari1,DarshanParekh
1,
Smita Bhandari1
1 Department of Interventional Endoscopy,
Thane Institute of Gastroenterology, Thane,
Maharashtra, India
Corresponding author
Suryaprakash Bhandari, MD
Thane Institute of Gastroenterology,
Department of Interventional Endoscopy,
Above Bank of Maharashtra, Vartak Nagar
Naka Pokhran Road No 1 Parel, Mumbai
Thane Maharashtra 400606, India
Fax: +9324007373
drsurya_b@yahoo.com
Acknowledgement
This video won the silver medal in the 2020
American Society for Gastrointestinal Endosco-
py Digestive Disease Week Endoscopy World
Cup.
References
[1] Akintoye E, Kumar N, Obaitan I et al. Peroral
endoscopic myotomy: a meta-analysis. En-
doscopy 2016; 48: 1059–1068
[2] Cho YK, Kim SH. Current status of peroral
endoscopic myotomy. Clin Endosc 2018; 51:
13–18
Bibliography
Endosc Int Open 2022; 10: E1307–E1308
DOI 10.1055/a-1889-4222
ISSN 2364-3722
© 2022. The Author(s).
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E1308 Bhandari Suryaprakash et al. Endoscopic management of …Endosc Int Open 2022; 10 : E1307–E1308 | © 2022. The Author(s).
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