Through-the-scope suture closure of peroral endoscopic myotomy mucosal incision sites

Abstract

Background Peroral endoscopic myotomy (POEM) is now widely used for esophageal motility disorders including achalasia. Closure of the mucosal incision site is a critical step of the procedure. We evaluated the use of a novel through-the-scope (TTS) suture system for closure of POEM mucosal incision sites.

Methods We retrospectively reviewed consecutive patients who underwent POEM with TTS suture closure at our institution between February and July 2021. Technical success was defined as complete mucosal incision site closure using TTS suturing, without the need for adjunctive devices. Continuous variables are presented as median (interquartile range [IQR]) or mean (SD).

Results 35 consecutive patients (median age 58 years [IQR 46.5–72]; 54.3 % female) underwent POEM with attempted mucosal closure by TTS suturing. Technical success was achieved in 32 patients (91.4 %) with a mean closure time of 12.4 (SD 6.9) minutes. The median mucosal incision length at time of closure was 2.5 cm (IQR 2–2.5). Overall, 17 patients (53.1 %) required ≥ 2 TTS suture systems and 3 patients (8.6 %) required additional TTS clips to achieve secure mucosal closure. No adverse events were encountered.

Conclusions TTS suturing was effective and safe for POEM mucosotomy closure. However, prospective comparative trials and cost-effectiveness analyses are warranted before routine adoption.

Publication History

Received: 29 January 2022

Accepted after revision: 30 May 2022

Article published online:
04 August 2022

• References

• 1 Khashab MA, Vela MF, Thosani N. et al. ASGE guideline on the management of achalasia. Gastrointest Endosc 2020; 91: 213-227
• 2 Kahrilas PJ, Katzka D, Richter JE. Clinical practice update: the use of per-oral endoscopic myotomy in achalasia: expert review and best practice advice from the AGA Institute. Gastroenterology 2017; 153: 1205-1211
• 3 Pescarus R, Shlomovitz E, Sharata AM. et al. Endoscopic suturing versus endoscopic clip closure of the mucosotomy during a per-oral endoscopic myotomy (POEM): a case–control study. Surg Endosc 2016; 30: 2132-2135
• 4 Hernandez Mondragon OV, Gutierrez-Aguilar R, Garcia Contreras LF. et al. Conventional clips vs over-the-scope-clips for the closure of the entry site in POEM and G-POEM procedures. Rev Esp Enferm Dig 2020; 112: 338-342
• 5 Hernandez A, Marya NB, Sawas T. et al. Gastrointestinal defect closure using a novel through-the-scope helix tack and suture device compared to endoscopic clips in a survival porcine model (with video). Endosc Int Open 2021; 9: E572-E577
• 6 Zhang LY, Bejjani M, Ghandour B. et al. Rethinking the need for overnight admission after peroral endoscopic myotomy (POEM): a pandemic-driven approach to the future. Endosc Int Open 2021; 9: E1381-E1385
• 7 Cotton PB, Eisen GM, Aabakken L. et al. A lexicon for endoscopic adverse events: report of an ASGE workshop. Gastrointest Endosc 2010; 71: 446-454
• 8 Zhang LY, Bejjani M, Ghandour B. et al. Endoscopic through-the-scope suturing. VideoGIE 2022; 7: 46-51
• 9 Modayil RJ, Zhang X, Rothberg B. et al. Peroral endoscopic myotomy: 10-year outcomes from a large, single-center U.S. series with high follow-up completion and comprehensive analysis of long-term efficacy, safety, objective GERD, and endoscopic functional luminal assessment. Gastrointest Endosc 2021; 94: 930-942
• 10 Benias PC, Korrapati P, Raphael KL. et al. Safety and feasibility of performing peroral endoscopic myotomy as an outpatient procedure with same-day discharge. Gastrointest Endosc 2019; 90: 570-578
• 11 Saxena P, Chavez YH, Kord Valeshabad A. et al. An alternative method for mucosal flap closure during peroral endoscopic myotomy using an over-the-scope clipping device. Endoscopy 2013; 45: 579-581
• 12 Zhang WG, Linghu EQ, Li HK. Fibrin sealant for closure of mucosal penetration at the cardia during peroral endoscopic myotomy: a retrospective study at a single center. World J Gastroenterol 2017; 23: 1637-1644
• 13 Johnson AM, Branch MS, Dufault DL. Successful management of persistent post-peroral endoscopic myotomy esophageal leak with fibrin glue. Gastrointest Endosc 2020; 92: 1124-1125
• 14 Yang D, Zhang Q, Draganov PV. Successful placement of a fully covered esophageal stent to bridge a difficult-to-close mucosal incision during peroral endoscopic myotomy. Endoscopy 2014; 46 Suppl 1: E467-468
• 15 Ichkhanian Y, Sanaei O, Canakis A. et al. Esophageal peroral endoscopic myotomy (POEM) for treatment of esophagogastric junction outflow obstruction: results from the first prospective trial. Endosc Int Open 2020; 8: E1137-E1143
• 16 Khashab MA, Sanaei O, Rivory J. et al. Peroral endoscopic myotomy: anterior versus posterior approach: a randomized single-blinded clinical trial. Gastrointest Endosc 2020; 91: 288-297
• 17 Ichkhanian Y, Abimansour JP, Pioche M. et al. Outcomes of anterior versus posterior peroral endoscopic myotomy 2 years post-procedure: prospective follow-up results from a randomized clinical trial. Endoscopy 2021; 53: 462-468
• 18 Reddy CA, Tavakkoli A, Abdul-Hussein M. et al. Clinical impact of routine esophagram after peroral endoscopic myotomy. Gastrointest Endosc 2021; 93: 102-106
• 19 El Khoury R, Teitelbaum EN, Sternbach JM. et al. Evaluation of the need for routine esophagram after peroral endoscopic myotomy (POEM). Surg Endosc 2016; 30: 2969-2974