Fibrin sealant for closure of mucosal penetration at the cardia during peroral endoscopic myotomy (POEM)

Abstract

Cardiac mucosal penetrations occurred during peroral endoscopic myotomy (POEM) in two patients with achalasia, and were treated by fibrin sealant. Case 1 was a 27-year-old man with dysphagia for over 1 year who underwent endoscopic botulinum injection, but dysphagia reoccurred just weeks later. During tunnel establishment a penetration was caused, probably by over-electrocautery from the submucosal space to the esophageal lumen near the cardia (• " Fig. 1 a). We sprayed fibrin sealant into the distal end of the submucosal tunnel under direct endoscopic vision to ensure that the fibrin sealant fully covered the hole (• " Fig.1 b). After 6 weeks, a repeat gastroscopy showed that the hole had healed well (• " Fig. 2). Dysphagia was relieved, with lower esophageal sphincter pressure decreased from 63.2 mmHg before POEM to 28.0 mmHg 4 months after. Case 2 was a 38-year-old woman with dysphagia for over 7 years who received balloon dilation first, but her dysphagia was not relieved.• " Fig. 3 shows the treat-

Endoscopic suturing versus endoscopic clip closure of the mucosotomy during a per-oral endoscopic myotomy (POEM): a case–control study

“…One important aspect of the technique is an adequate closure of the initial mucosal entry site. Various case reports have presented alternatives to the through-thescope clips [6,7,9], although in most centers, endoscopic clips seem to be the standard closure technique. Currently, no objective comparison between the different mucosotomy closure techniques has been published.…”

Fibrin sealant for closure of mucosal penetration at the cardia during peroral endoscopic myotomy: A retrospective study at a single center

“…However, some major perioperative adverse events from POEM have also been reported, with mucosal penetration being one of the most dangerous adverse events[1,2,5,6]. Mucosal penetration during POEM occurs at a rate ranging from 4.2%-17.3% depending on the study[1,2,5,7]. Treatment for this complication has varied, with some patients undergoing observation without special treatment, being sealed by multiple clips or an endoscopic suture device (OverStitch™ Endoscopic Suturing System; Apollo Endosurgery Austin, Texas), or being treated with the defect being closed using fibrin sealant[11-15].…”

“…Mucosal penetration usually occurs at the cardia, where a myotomy is performed during POEM. We previously reported the usage of fibrin sealant for mucosal penetration at the cardia in two cases in 2012[7]. However, long-term outcomes with a larger population are needed to further assess this treatment strategy.…”

Complications of submucosal endoscopy

“…Several techniques have been described to close a mucosal defect successfully, such as regular clips [17,36,37], fibrin sealant [38], and even stitches (Overstitch™, Appolo Endosurgery, Austin, USA) [39]. However, the easiest technique that can be used more realistically is the application of regular endoclips, because the defect is usually very small and induced by the tip of the knife.…”