Delayed Intrathoracic Gastric Perforation after G-POEM for Treating Post-Operative Refractory Gastroparesis฀A Case Report and Review of Literature

Background: Gastric peroral endoscopic pyloromyotomy(G-POEM) is introduced as a strategy to treat post-operative refractory gastroparesis. An intrathoracic gastric perforation is a rare complication of G-POEM. Case presentation: This report described the case of a patient who suffered with an intrathoracic gastric perforation about 10 days after a G-POEM procedure. A review of the PUBMED literature indexed in English with the key words of perforation and G-POEM was performed and the results were considered. The results indicated that delayed perforation was a rare complication after G-POEM. Overeating may cause the severe intrathoracic gastric dilation and perforation. Furthermore, successful nonsurgical management after G-POEM complicated by delayed perforation could be a highly feasible option, if intensive conservative treatments were used. Conclusions: Delayed perforation after G-POEM treating post-operative refractory can lead to severe mediastinal and thoracic infections. Fully prepared before the G-POEM procedure and effective suture instrument during the procedure may reduce the incidence of perforations. If perforation occurs after G-POEM, conservative treatment can be chosen if a patient’s general situation allows. However, the choice of surgical treatment must not be ignored if the patient's overall condition deteriorates.


Background
Gastroparesis is a chronic disorder whose feature is the symptoms of delayed gastric emptying, such as nausea and vomiting, without mechanical obstruction [1]. Major causes of gastroparesis are diabetic, postsurgical, and idiopathic [2,3]. Severe consequences for nutritional and their psychological status may be caused by this disease. Indeed, medical treatments are ineffective over time and can also cause adverse events and tachyphylaxia [4][5][6]. So far, various interventional therapies have also been frustrating. Gastric peroral endoscopic pyloromyotomy (G-POEM) is now introduced as a strategy to treat refractory gastroparesis. Mucosal perforation and bleeding are the major adverse events. Complications that occur during the G-POEM procedure can be treated endoscopically (clips). However, delayed perforation is difficult or impossible to treat with clips. Here we present a case of a patient with an intrathoracic gastric perforation, about 10 days after he underwent a G-POEM procedure for the treatment of post-operative refractory gastroparesis. In addition, we analyzed and summarized the characteristics and treatments of this complicationg with a review of the previous cases.  (Fig. 1). The patient fasted on the first day after the G-POEM procedure, then was approved to resume the intake of an oral liquid diet followed by initiation of a soft diet. The patient was given intravenous antibiotics for 48 hours and was discharged 7 days after G-POEM. At 10 days after G-POEM, the patient was re-admitted to our department with difficulty breathing and acute onset of abdominal, chest pain after after a full meal. Physical examination showed a respiratory rate of 30 per minute. Auscultation of the chest revealed a reduction in the right breathing sounds. Computed tomography (CT) scan showed right thoracic stomach and right pleural effusion ( Fig. 2A). Gastroscopy showed that the clips were detached and the mucosa was torn (Fig. 2B). A nasojejunal tube and a nasogastric tube were placed (Fig. 2C). A chest drainage was also placed to remove the purulent fluid. Enteral nutrition and intravenous antibiotic therapy were given. Gastrointestinal radiography showed no contrast medium leakage on postoperative day (POD) 34. As a result, oral feeding was initiated, and the patient was discharged on POD 56.

Discussion and conclusions
G-POEM has become a therapeutic intervention to refractory gastroparesis since it was first described by Chaves DM et al in 2014 [7]. The efficacy and safety of the procedure have been reported in many previous studies [8,9]. There have also been reports on adverse events such as delayed bleeding, mucosal tears , or perforation [10,11] . Delayed gastric perforation, which occurs after the procedure is rare, and only one human case reported in the literature were searched on PubMed , the clinical features treatment and outcomes were summarized in Table 1.

Availability of data and materials
All the original data supporting our research are described in this article.

Ethics approval and consent to participate
The study was approved by the ethics committee of Affiliated Renmin Hospital of Jiangsu University. The patient gave consent to participate.

Consent for publication
Informed consent was obtained from all individual participants included in the study.