ENDOSCOPIC MANAGEMENT OF AN INTRAPARIETAL OESOPHAGEAL HEMATOMA, SECONDARY COMPLICATION OF POEM IN A TYPE 1 ACHALASIA, PREVIOUSLY TREATED BY HELLER MYOTOMY

Achalasia is an idiopathic condition characterized by abnormally elevated pressure of the lower oesophageal sphincter (LES) and abnormal oesophageal peristalsis. Before per oral endoscopic myotomy (POEM) the treatment was either by drugs (nitrates, calcium blockers), endoscopic pneumatic dilatation or by surgical myotomy.

Endoscopic myotomy is more and more popular in expert endoscopic centers because of highefficacy (90%) and low complication rate (5%).

We report the case of a 56 years old patient with a type 1 Achalasia that was previously treated by Heller myotomy. He remained asymptomatic for 4 years after the procedure, but later restarted having dysphagia, odynophagia an alimentary regurgitations.

After pluridisciplinary concertation, it was decided to propose long posterior POEM.

We performed a long submucosal tunnel followed by a selective circular myotomy of 13 cm with a HookKnife 620LR (Olympus Tokyo, Japon). We had no particular hemorrhagic complications during endoscopic procedure.

Three hours after the procedure, the patient had post procedural severe retrosternal pain and nausea. The CT scan confirmed a 60 mm esophageal hematoma with possible active intraparietal bleeding.

We decided for immediate endoscopic intervention because of the high risk of mediastinitis and the active bleeding.

We removed the clips that closed the mucosal defect and after access in the submucosal tunnel we removed the blood cloths with polypectomy snares. There was active bleeding from a perforating intramuscular vessel that was treated with coagulation, using a hot forceps (Cook Medical, Bloomington, USA). We closed the tunnel incision with 6 clips Resolution 360 (Boston Scientific, USA). The patient felt immediately better and was finally discharged 5 days later. No other complication was reported after 4 months of follow up.

POEM is possible even after previous surgical myotomy. We report the successful endoscopic treatment of a large intraparietal hematoma and active bleeding.