VIDEOGIE Todd H. Baron, MD, G. S. Raju, MD, Editors for VideoGIE
Endoscopic suture repair of a large mucosal perforation during peroral endoscopic myotomy for treatment of achalasia
Figure 1. Published POEM series reports on accidental mucosal perforation.
Mucosal perforations occur in about 10% to 15% of peroral endoscopic myotomy (POEM) procedures and are usually closed with clips. However, accidental perforations because of submucosal fibrosis from prior Botox (Allergan Inc., Irvine, CA) injections, balloon dilations (BDs), or other manipulations can be difficult to close (Fig. 1). A 40-year-old man with stage 2, type I achalasia and multiple prior BDs underwent POEM for dysphagia. Extensive submucosal fibrosis from prior BDs made extension of the tunnel at the gastroesophageal junction challenging. The first mucosal perforation at the squamocolumnar junction was closed immediately with endoclips. A second accidental perforation occurred after the tunnel extended into the cardia. Closure was postponed until the myotomy was completed because there was concern of tunnel narrowing, hindering the myotomy. However, at the completion of the myotomy, the cardia perforation dramatically enlarged, likely because of the CO2 insufflation within the tunnel. Given its large size and poor tissue quality, endoscopic suturing was used to successfully close this www.giejournal.org
perforation. It was noted then that the prior clip closure of the other perforation had dehisced. The clips were removed, and sutured closure was performed using the Overstitch endoscopic suturing system (Apollo Endosurgery, Inc, Austin, Tex). Despite extensive mucosal plication at the gastroesophageal junction, a patulous lower esophageal sphincter opening remained, which is consistent with successful myotomy. The patient was discharged within 48 hours without concern for delayed leak. He had an Eckardt score of 0 at 1 and 3 months after POEM. This is the first report of endoscopic suturing used for this indication (Video 1, available online at www.giejournal. org).
DISCLOSURE The following authors disclosed financial relationships relevant to this publication: S. N. Stavropoulos: Honorarium from Erbe and Boston Scientific. All other authors Volume
-,
No.
-
: 2014 GASTROINTESTINAL ENDOSCOPY 1
VideoGIE
disclosed no financial relationships relevant to this publication.
and Nutrition, Winthrop University Hospital, Mineola, New York, USA
Rani Modayil, MD, David Friedel, MD, Stavros N. Stavropoulos, MD, Division of Gastroenterology, Hepatology,
http://dx.doi.org/10.1016/j.gie.2014.03.035
2 GASTROINTESTINAL ENDOSCOPY Volume
-,
No.
-
: 2014
www.giejournal.org
Endoscopic suture repair of a large mucosal perforation during peroral endoscopic myotomy for treatment of achalasia
Figure 1. Published POEM series reports on accidental mucosal perforation.
Mucosal perforations occur in about 10% to 15% of peroral endoscopic myotomy (POEM) procedures and are usually closed with clips. However, accidental perforations because of submucosal fibrosis from prior Botox (Allergan Inc., Irvine, CA) injections, balloon dilations (BDs), or other manipulations can be difficult to close (Fig. 1). A 40-year-old man with stage 2, type I achalasia and multiple prior BDs underwent POEM for dysphagia. Extensive submucosal fibrosis from prior BDs made extension of the tunnel at the gastroesophageal junction challenging. The first mucosal perforation at the squamocolumnar junction was closed immediately with endoclips. A second accidental perforation occurred after the tunnel extended into the cardia. Closure was postponed until the myotomy was completed because there was concern of tunnel narrowing, hindering the myotomy. However, at the completion of the myotomy, the cardia perforation dramatically enlarged, likely because of the CO2 insufflation within the tunnel. Given its large size and poor tissue quality, endoscopic suturing was used to successfully close this www.giejournal.org
perforation. It was noted then that the prior clip closure of the other perforation had dehisced. The clips were removed, and sutured closure was performed using the Overstitch endoscopic suturing system (Apollo Endosurgery, Inc, Austin, Tex). Despite extensive mucosal plication at the gastroesophageal junction, a patulous lower esophageal sphincter opening remained, which is consistent with successful myotomy. The patient was discharged within 48 hours without concern for delayed leak. He had an Eckardt score of 0 at 1 and 3 months after POEM. This is the first report of endoscopic suturing used for this indication (Video 1, available online at www.giejournal. org).
DISCLOSURE The following authors disclosed financial relationships relevant to this publication: S. N. Stavropoulos: Honorarium from Erbe and Boston Scientific. All other authors Volume
-,
No.
-
: 2014 GASTROINTESTINAL ENDOSCOPY 1
VideoGIE
disclosed no financial relationships relevant to this publication.
and Nutrition, Winthrop University Hospital, Mineola, New York, USA
Rani Modayil, MD, David Friedel, MD, Stavros N. Stavropoulos, MD, Division of Gastroenterology, Hepatology,
http://dx.doi.org/10.1016/j.gie.2014.03.035
2 GASTROINTESTINAL ENDOSCOPY Volume
-,
No.
-
: 2014
www.giejournal.org
