Infected esophageal subepithelial hematoma after peroral endoscopic myotomy for achalasia successfully treated with double-pigtail stent drainage

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.

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Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Kahrilas PJ, Katzka D, Richter JE. Clinical practice update: the use of per-oral endoscopic myotomy in achalasia: expert review and best practice advice from the AGA Institute. Gastroenterology 2017; 153: 1205-1211
• 2 Ren Z, Zhong Y, Zhou P. et al. Perioperative management and treatment for complications during and after peroral endoscopic myotomy (POEM) for esophageal achalasia (EA) (data from 119 cases). Surg Endosc 2012; 26: 3267-3272
• 3 Benech N, Pioche M, O’Brien M. et al. Esophageal hematoma after peroral endoscopic myotomy for achalasia in a patient on antiplatelet therapy. Endoscopy 2015; 47: E363-E364
• 4 Donatelli G, Fuks D, Cereatti F. et al. Endoscopic transmural management of abdominal fluid collection following gastrointestinal, bariatric, and hepato-bilio-pancreatic surgery. Surg Endosc 2018; 32: 2281-2287
• 5 Dohi O, Dohi M, Inoue K. et al. Endoscopic transgastric drainage of a gastric wall abscess after endoscopic submucosal dissection. World J Gastroenterol 2014; 20: 1119-1122

Publication History

Article published online:
22 January 2020