Department of General Surgery, Providence Portland Cancer Center, Portland, OR, USA,
Surg Endosc. 2013 Oct;27(10):3910. doi: 10.1007/s00464-013-3002-8. Epub 2013 May 25.
Per-oral endoscopic myotomy (POEM) requires advanced flexible endoscopic skills, especially in the management of complications.
We present a full-thickness esophagotomy while performing POEM and repair using an endoscopic suturing device.
An anterior esophageal 2 cm mucosectomy is created 7-10 cm proximal to the gastroesophageal junction after a submucosal wheal is raised. A submucosal tunnel is created and extended to 2 cm on the gastric cardia. A selective circular myotomy is performed. The mucosectomy is closed using endoscopic clips.
An inadvertent full-thickness esophagotomy was created while performing the mucosotomy on an inadequate submucosal wheal. We were able to resume the POEM technique at the initial esophagotomy site. There was a discussion to convert to laparoscopy. However, as we succeeded in creating the tunnel, we continued with the POEM technique. After the selective myotomy was completed, we used an endoluminal suturing device (Overstitch, Apollo Endosurgery, Austin TX) to close the full-thickness esophagotomy in two layers (muscular, mucosal). A covered stent was not an option because the esophagus was dilated, which precluded adequate apposition. The patient had an uneventful postoperative course. At 9-month follow-up, had excellent palliation of dysphagia without reflux.
This case demonstrates the importance of identifying extramucosal intrathoracic anatomy, thus emphasizing the need for an experienced surgeon to perform these procedures, or at a minimum to be highly involved. Raising an adequate wheal is crucial before mucosectomy. Inadequacy of the wheal may reflect local esophageal fibrosis. If this fails at multiple locations in the esophagus, it may be prudent to convert to laparoscopy. This case also demonstrates the need for advanced flexible endoscopic therapeutic tools and a multidisciplinary approach to manage potential complications.
经口内镜下肌切开术（POEM）需要先进的灵活内镜技能，尤其是在处理并发症方面。
我们在进行 POEM 时发生全层食管切开，并使用内镜缝合装置进行修复。
在胃食管交界处近端 7-10cm 处创建一个前食管 2cm 黏膜切除术，在黏膜下隆起处创建一个黏膜下隧道，并向胃贲门延伸 2cm。进行选择性环形肌切开术。使用内镜夹闭合黏膜切除术。
在对不足的黏膜下隆起进行黏膜切除时，无意中造成全层食管切开。我们能够在初始食管切开部位恢复 POEM 技术。曾讨论过转为腹腔镜。然而，由于我们成功地创建了隧道，因此继续使用 POEM 技术。选择性肌切开术完成后，我们使用腔内缝合装置（Overstitch，Apollo Endosurgery，Austin TX）将全层食管切开两层（肌肉层、黏膜层）缝合。由于食管扩张，覆盖支架不是一个选择，因为这会妨碍充分贴合。患者术后恢复顺利。在 9 个月的随访中，吞咽困难得到了极好的缓解，没有反流。
本病例强调了识别食管外胸腔内解剖结构的重要性，因此需要有经验的外科医生来进行这些手术，或者至少要高度参与。在进行黏膜切除之前，隆起一个足够的隆起是至关重要的。如果食管多个部位的隆起不足，可能需要转为腹腔镜。本病例还表明需要先进的灵活内镜治疗工具和多学科方法来处理潜在的并发症。
Zotero 插件