S5307 Sealing the Gap: Innovative Use of Fibrin Sealant in Z-POEM Complication Management

Introduction: Zenker’s diverticulum (ZD) is a pulsion diverticulum occurring at the pharyngoesophageal junction, predominantly affecting elderly individuals. Traditional surgical approaches have been the mainstay of treatment; however, peroral endoscopic myotomy for Zenker’s diverticulum (Z-POEM) has emerged as a minimally invasive alternative, demonstrating high technical and clinical success rates. During Z-POEM, effective closure of the mucosal entry is crucial to prevent complications such as perforations, bleeding, pneumoperitoneum, and pneumothorax. Common closure techniques include endoscopic clips and suturing devices. Fibrin sealant has also been utilized for mucosal closure, offering a safe and effective option. Case Description: A 65-year-old woman presented for Z-POEM repair of a symptomatic Zenker’s diverticulum. Initial endoscopy was performed with successful myotomy and closure of the mucosotomy using endoclips. Post-procedure, the patient developed prevertebral and retropharyngeal soft tissue stranding with gas and pneumomediastinum, indicating a failure of the proximal aspect of the mucosotomy closure. A repeat endoscopy revealed dehiscence at the proximal closure site. Lavage with gentamicin was performed, followed by an attempt at endoscopic suturing; however, clinical improvement was not observed. Subsequently, another endoscopy was conducted, during which argon plasma coagulation (APC) was applied, and fibrin sealant was utilized to achieve closure. A nasogastric tube was placed for enteral feeding and removed after 72 hours. The patient tolerated a clear liquid diet for 2 days, which was then advanced to a full liquid diet. She was discharged without complications and demonstrated spontaneous resolution of the pneumomediastinum upon clinical follow-up. Discussion: This case highlights the potential utility of fibrin sealant as an adjunctive measure in the closure of mucosotomy defects during Z-POEM, particularly in instances where traditional methods such as clips or sutures are inadequate. While endoscopic clips and suturing devices are commonly employed for mucosal closure, fibrin sealant offers a viable alternative, especially in challenging cases. Further studies are warranted to evaluate the efficacy and outcomes associated with fibrin sealant in this context.