Endoscopic management of esophagomediastinal fistula following peroral endoscopic myotomy.

OBJECTIVES

Esophagomediastinal fistula (EMF) is a rare but important major adverse event (mAE) after peroral endoscopic myotomy (POEM), which is scarcely reported. This study aimed to offer a comprehensive analysis of the evaluation and management of EMF following POEM.

METHOD: From June 2015 to December 2023, we retrospectively reviewed patients with achalasia receiving POEM. Patients diagnosed with postoperative EMF were included. Clinical characteristics, outcomes, and follow-up of EMF were analyzed.

RESULTS

There were 10 cases of EMF in patients (6 men; median age 37 years). The location of the EMF was the tunnel's entrance (3 cases) and the middle of the tunnel (7 cases). The most common accompanying symptoms were febrile episodes (9 cases), retrosternal pain (5 cases), and chest tightness (3 cases). The findings of the initial postoperative CT scan included pleural effusion (6 cases), pneumothorax (4 cases), mediastinal emphysema or effusion (4 cases), and subcutaneous emphysema (1 case). The median duration from POEM procedure to the diagnosis of the fistula was 8 days (range 4-18). The fistula was successfully controlled by nasogastric tube combined with nasojejunal tube insertion (8 cases), gastric drainage tube inserted into the tunnel (5 cases), debridement within the tunnel (4 cases), tunnel mucosal incision (1 case). No patient required surgical intervention. All patients received antibiotics and nutritional support. Eight patients required thoracic drainage. The median post-fistula and total hospital stays were 25 days (range 13-54) and 22 days (range 11-51), respectively.

CONCLUSIONS

This comprehensive management approach demonstrated its effectiveness, and all EMFs were successfully treated without requiring subsequent surgical interventions.