Maintaining the integrity of the mucosal flap and the reliable closure of mucosal
entry during peroral endoscopic myotomy (POEM) is paramount in preventing leakage
of esophageal contents into the mediastinal space. We describe our experience with
POEM, the problems encountered with closure of mucosal flaps, and successful closure
with over-the-scope clips (OTSC). Two patients with achalasia underwent successful
endoscopic myotomy during POEM. During both procedures, the proximal end of the longitudinal
mucosal incision was noted to be gaping and completion of the closure with standard
clips was unsuccessful. The sides of the flap were approximated using a Twin Grasper
followed by placement of OTSC. Closure of the mucosal entry appeared to be complete
at the end of the procedures. Esophagram the following day revealed no leaks in either
patient. There were no other complications and patients were discharged home after
1 – 2 days of hospital observation. Patients reported complete resolution of achalasia
symptoms during follow-up. We propose closure of mucosal incisions during POEM using
one to two OTSC as an alternative to described techniques. The use of OTSC may simplify
the procedure and result in a more durable (i. e. full-thickness) closure.
