1074 ENDOSCOPIC MANAGEMENT OF MUCOSAL INCISION SITE DEHISCENCE FOLLOWING POEM PROCEDURE.

Abstract

A 39 Yrs old male patient underwent POEM for primary achalasia cardia.Post procedure, on day 3, he developed one spike of fever and retrosternal discomfort requiring higher requirement of analgesics. A chest X ray showed no e/o any mediastinal collection.On check upper GI Endoscopy, there was e/o mucosal incision dehiscence with purulent discharge and lots of slough in the tunnel. The submucosal tunnel showed signs of inflammation and infection, although the myotomy layer had healed completely with no mediastinal leak seen.The clips were removed and wash was given in the submucosal tunnel. Mucosal incision was reapproximated with endoscopic clips. An NJ tube was inserted for feeds. Patient was given intravenous antibiotics.The patient did show some improvement clinically for pain but continued to have fever spikes. A CT scan thorax with oral contrast was done which did not reveal any esophageal leak.Check scopy on day 6 again showed mucosal incision dehiscence with purulent discharge. All clips were removed and submucosal tunnel was laid open by cutting the whole mucosa with needle knife till the lower end of the tunnel. The principle was to allow the pus to drain adequately and let the mucosa heal by secondary intention. This would also prevent any leak in the mediastinum due to persistent infection.Patient improved symptomatically and subsequent check scopy on day 9 showed development of granulation tissue with signs of healing. Follow up check scopy on day 17 showed complete mucosal healing. In conclusion, mucosal incision site dehiscence is an extremely rare complication of POEM. In our case it was most probably due to loose application and/or application of one or more clips only on one wall of the mucosal edge, hence preventing water tight closure. For prevention of this complication, water tight closure of mucosal incision is extremely important. Once discovered, it is imperative to rule out any muscle defect.And timely management by opening up mucosa and draining pus is a safe and effective treatment to prevent hazardous mediastinal leak.