Closing the gap in POEM

We have read with interest the paper from Saxena et al., reporting their experience with over-the-scope clips (OTSCs) as an alternative technique for mucosal entry closure during peroral endoscopic myotomy (POEM) in two cases [1]. We concur with their assessment that given the larger mouth and higher compressive force of OTSCs compared with standard clips [2] [3] [4], the OTSC may be a more suitable tool for the management of difficult mucosal closures in POEM.

Our impression is based on our experience with POEM, in which closure of the mucosotomy site in a patient was complicated by the inverted edges of the incision ([ Fig. 1 ]). Multiple attempts (over 25 clips were deployed) with different standard clips (Resolution Clip, Boston Scientific, Natick, Massachusetts, USA; and Instinct Clip, Cook Medical, Winston-Salem, North Carolina, USA) failed to bridge the incisional gape. After spending in excess of 60 minutes on this closure process and due to the increasing risk of partially attached clips falling into the submucosal tunnel, we decided to use the OTSC instead. We were able to easily appose the incisional edges within the cap using the twin grasper and successfully deploy the OTSC, closing the entry site in less than 5 minutes ([ Fig. 2 ]). A post-procedural esophagram revealed no leakage and there were no associated complications ([ Fig. 3 ]).

Fig. 1 Mucosal incision with inverted edges.

Fig. 2 Closure of mucosal incision with the over-the-scope clip.

Fig. 3 Esophagram with water-soluble contrast following peroral endoscopic myotomy.

In conclusion, OTSCs can be a valuable tool for closure of the mucosal entry site during POEM. Similarly to Saxena et al., we failed to close the mucosal incision after a significant amount of time and utilizing a large number of standard clips. Therefore, one can consider the OTSC as a primary option for technically challenging cases of mucosal entry closure during POEM.

• References

• 1 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; In press.
• 2 von Renteln D, Vassiliou MC, Rothstein RI. Randomized controlled trial comparing endoscopic clips and over-the-scope clips for closure of natural orifice transluminal endoscopic surgery gastrotomies. Endoscopy 2009; 41: 1056-1061
• 3 Banerjee S, Barth BA, Bhat YM et al. Endoscopic closure devices. Gastrointest Endosc 2012; 76: 244-251
• 4 Baron TH, Wong Kee Song LM, Zielinski MD et al. A comprehensive approach to the management of acute endoscopic perforations (with videos). Gastrointest Endosc 2012; 76: 838-859