Pooling of barium at mucosotomy site after peroral endoscopic myotomy on Barium Swallow Study

Peroral endoscopic myotomy (POEM) is a minimally invasive, incisionless alternative to Heller myotomy for treatment of Achalasia. It is still an evolving procedure done only at expert centers. We report an interesting post-procedure radiological finding that might be helpful in managing patients undergoing this procedure. A 24-year-old woman with advanced Achalasia underwent POEM performed in the standard method after which she was kept nil per oral on intravenous antibiotics. Barium swallow study done on the next day showed free passage of barium into stomach with no leak but there was pooling of a small amount of barium in the submucosal space at the upper end of the mucosotomy site without passage down the tunnel into the mediastinum. X-ray showed intact endoscopic clips at the mucosotomy site. Patient was afebrile and only had the expected post-procedure mild chest discomfort. She was continued nil per oral for an additional day and Barium swallow study was repeated which did not show any further pooling of barium at the mucosotomy site and the barium had passed freely into the stomach without a leak. Pooling of a small amount of barium at the mucosotomy site was likely due to the passage of barium into the submucosal space between the clips as they might not have created watertight closure of mucosotomy. This finding is usually of no clinical consequence if barium does not leak out through the tunnel into the mediastinum. Starting myotomy at least 2–3 cm distal to mucosotomy site such that the submucosal space closes off by mucosal flap above the myotomy site and meticulous, watertight closure of mucosotomy site may prevent such occurrence.