Peroral endoscopic myotomy (POEM) has proven similarly effective to and less invasive
than laparoscopic Heller myotomy and become the preferred option for the treatment
of esophageal achalasia [1]. Few post-operative adverse events have been reported, among them a very low incidence
of delayed bleeding causing a submucosal hematoma that could be treated with conservative
management [2]
[3].
We report a case of a 47-year-old man who underwent a successful POEM for a type of
esophageal achalasia. He was readmitted to our center 10 days later for worsening
epigastric pain with fever. A CT scan showed a right-side esophageal subepithelial
collection ([Fig. 1]). An infected submucosal hematoma was diagnosed. Despite initial conservative treatment
with a broad-spectrum antibiotic and anti-fungal, the patient continued to be septic.
After multidisciplinary discussion, we decided to drain the submucosal abscess endoscopically.
During the procedure ([Video 1]), a small ulcerated orifice with discharged pus was seen on the previous POEM tunnel.
We cannulated the submucosal space via this orifice with a guidewire and then placed
a 7 French double-pigtail stent under endoscopic ultrasound control and fluoroscopic
guidance ([Fig. 2]). A significant clinical and biological improvement was achieved, and the patient
was discharged home the next day with an oral antibiotic. A 10-day follow-up CT scan
revealed complete resolution of the collection with the stent in place, which was
planned for removal in 1 month ([Fig. 3]).
Fig. 1 CT scan shows a large esophageal tunnel hematoma.
Video 1 Successful double-pigtail stent drainage of infected esophageal subepithelial hematoma
after peroral endoscopic myotomy for achalasia.
Fig. 2 Endoscopic drainage procedure. a Small ulcerated orifice on the previous POEM tunnel. b Insertion of 7 French double-pigtail stent. c Guidewire placement in the tunnel via the orifice. d Placement of 7 French double-pigtail stent under fluoroscopic guidance.
Fig. 3 10-day follow-up CT scan showed complete resolution of the collection with the stent
in place.
Even though a post-POEM submucosal hematoma is rare and can resolve spontaneously,
infection can occur and might require additional management. The feasibility and efficacy
of endoscopic transmural drainage of an intra-abdominal collection was already well
established [4]. It was also demonstrated to be feasible for a gastric wall abscess after endoscopic
submucosal dissection [5]. We believe that this is the first case of an infected hematoma post-POEM for which
a short procedure of endoscopic drainage was also very effective.
Endoscopy_UCTN_Code_CPL_1AH_2AJ
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high quality video and all
contributions are freely accessible online.
This section has its own submission website at https://mc.manuscriptcentral.com/e-videos
