Pooling of Barium at Mucosotomy Site After Peroral Endoscopic Myotomy For Achalasia

Abstract

Introduction: A 24-year-old woman with achalasia underwent Peroral endoscopic myotomy (POEM). POEM was performed in standard steps including vertical mucosotomy on the anterior wall in the mid esophagus, creation of submucosal tunnel by submucosal dissection, selective myotomy of circular muscle starting 3cm distal to mucosotomy site extending 4cm into the cardia and closure of mucosotomy using endoscopic clips. The mucosotomy was about 2 cm long and 8 endoscopic clips (Wilson Cook, NC, USA) were used to close the mucosotomy site. Patient was kept nil per oral along with intravenous antibiotics and a barium swallow study was performed next day. It showed free passage of barium into stomach without a leak, however, there was pooling of small amount of barium in the submucosal space at upper end of the mucosotomy site adjacent to endoclips, without passage down the tunnel (figure 1). Patient was afebrile with normal white count except for mild chest discomfort as expected post-procedure. Patient was continued nil per oral for an additional day and a barium swallow study was repeated. It did not show any further pooling of barium at the mucosotomy site and it passed freely into the stomach without a leak (figure 2). Clear liquid diet was started and she was discharged home. Pooling of small amount of barium at the mucosotomy site was likely due to passage of barium into submucosal space between the clips as they might not have caused water tight closure of mucosotomy. However, this finding is usually of no clinical consequence especially if barium does not leak out through the tunnel into the mediastinum. Meticulous and water tight closure of mucosotomy site might have prevented this. It is also important to start myotomy at least 2-3 centimeters distal to mucosotomy site such that the submucosal space closes off above the myotomy site and acts as a safety cushion.Figure 1Figure 2