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

Table 1 Clinical characteristics and procedure-related parameters for 21 consecutive patients who experienced mucosal penetration during peroral endoscopic myotomy procedure

Patient characteristics
Sex, female/male (n)	12/9
Age (yr), mean (range)	38.0 (15-64)
Symptom duration (mo), median (range)	26.0 (10-360)
Previous treatment (n)
Botox injection	3
Bouginage	1
Chicago classification (n)
Type I	2
Type II	18
Type III	1
Procedure-related parameters
Procedure time (min.), median (range)	58.9 (20.0-141.0)
Tunnel length (cm), mean (range)	11.7 (7-18)
Myotomy length (cm), mean (range)	5.6 (3-10)
Myotomy type (n)
Inner circular muscle myotomy	10
Full-thickness myotomy	1
Glasses-style anti-reflux myotomy	1
Progressive full-thickness myotomy	9

Table 2 Characteristics of the 21 mucosal penetrations and the treatment outcomes using fibrin sealant

Penetration shape, n (%)
Hole-like penetration	12 (57.1)
Linear penetration	9 (42.9)
Penetration location
Esophageal part of cardia	12 (61.9)
Stomach part of cardia	8 (38.1)
Both esophageal and stomach parts of cardia	1 (4.8)
Penetration size
Hole like penetration (cm2), mean (range)	0.14 (0.02-0.32)
Linear penetration (cm), median (range)	0.37 (0.10-1.00)
Consumed fibrin sealant amount (n)
5.0 mL	3
2.5 mL	18
Postoperative treatment
Placement of nasogastric tube (n)	2
Postoperative stay (d), median (range)	5 (5-7)

Table 3 Detailed data of the mucosal penetrations from all 21 patients

Number	Shape	Location	Estimated size (cm/cm2)	Postoperative treatment	Postoperative stay (d)	Amount of consumed fibrin sealant (mL)	Postoperative complaint
1	Hole like	GOC	0.4 × 0.4	NG tube	7	5	Slight abdominal pain
2	Hole like	GOC	0.4 × 0.5	NG tube	7	2.5	Normal
3	Hole like	GOC	0.3 × 0.2	Fasting	7	2.5	Normal
4	Linear	EOC	0.3	Fasting	7	2.5	Normal
5	Hole like	EOC	0.4 × 0.3	Fasting	7	2.5	Normal
6	Linear	EOC	0.3	Fasting	6	2.5	Normal
7	Linear	EOC	0.1	Fasting	6	2.5	Normal
8	Linear	GOC	0.4	Fasting	6	2.5	Normal
9	Linear	GOC	0.4	Fasting	6	2.5	Normal
10	Hole like	EOC	0.3 × 0.2	Fasting	5	2.5	Normal
11	Linear	EOC	0.2	Fasting	5	2.5	Normal
12	Hole like	EOC	0.2 × 0.2	Fasting	5	2.5	Normal
13	Linear	BOC	1.0	Fasting	5	5	Normal
14	Hole like	EOC	0.8 × 0.4	Fasting	5	2.5 (one hemostatic clip)	Normal
15	Linear	EOC	0.3	Fasting	5	2.5	Normal
16	Hole like	GOC	0.5 × 0.5	Fasting	5	2.5	Normal
17	Hole like	EOC	0.4 × 0.4	Fasting	5	2.5	Normal
18	Hole like	GOC	0.3 × 0.3	Fasting	5	2.5	Normal
19	Hole like	EOC	0.4 × 0.4	Fasting	5	2.5	Normal
20	Linear	GOC	0.3	Fasting	5	2.5	Normal
21	Hole like	EOC	0.1 × 0.2	Fasting	5	2.5	Normal

NG tube: Nasogastric tube; GOC: Gastric part of the cardia; EOC: Esophageal part of the cardia; BOC: Both gastric and esophageal parts of the cardia.

Table 4 Symptom relief, manometry outcomes, and reflux complications of the 21 patients who experienced mucosal penetration during peroral endoscopic myotomy

Follow-up period (mo), median (range)	42.0 (9-62)
Symptom relief
Eckardt score, median (range)
Pre-treatment	5.0 (4-10)
Post-treatment	1.0 (0-4)
Pre/post-treatment difference value	4.8 (1-9)
Treatment success (Eckardt score ≤ 3), n (%)	20 (95.2)
Manometry outcomes
Manometry follow-up rate, n (%)	15 (71.4)
LESP (mmHg), median (range)
Pre-treatment	31.9 (21.9-67.1)
Post-treatment	20.3 (6.0-41.0)
Pre/post-treatment difference value	14.1 (9.6-35.2)
Post-POEM esophagitis on EGD
LA-A	1
LA-B	2
Overall, n (%)	3 (14.3)
Gas-related complications, n
Pneumothorax	1
Pneumoperitoneum	1
Pneumomediastinum	1
Overall	3

POEM: Peroral endoscopic myotomy; EGD: Esophagogastroduodenoscopy; LA-A: Los Angeles classification A; LA-B: Los Angeles classification B; LESP: Lower esophageal sphincter pressure.