Clip-anchoring technique: a fast, cheap, and efficient way to close a gastric peroral endoscopic pyloromyotomy tunnel

Gastric peroral endoscopic pyloromyotomy (G-POEM) is a treatment option for refractory gastroparesis [1]. The technique is similar to the esophageal peroral endoscopic myotomy [2]. However, tunnel closure may be difficult because of the gastric mucosa stretching at the end of the procedure.

We report here the case of a 38-year-old woman suffering from severe diabetic gastroparesis. She had already undergone unsuccessful pyloric botulinum toxin injections. The gastric emptying time was 146 minutes at preoperative scintigraphy.

We decided to perform a G-POEM ([Video 1]). After the submucosal injection, a 1-cm incision was made using an Endocut I effect 2 current, 5 cm above the pylorus. Immediately after, the same current was used to make three small incisions on each side of the tunnel entrance ([Fig. 1]) to allow clip anchoring at the end of the procedure. The rest of the procedure was a standard G-POEM: after the submucosal trimming inside the tunnel to the pyloric arch, a deep pyloromyotomy was made. The previously made incisions were used to place three clips to ease the tunnel closure (clip anchoring technique, [Fig. 2], [Fig. 3], [Fig. 4]). The overall procedure lasted 25 minutes and the tunnel closing lasted 3 minutes. There were no complications after the procedure, except an early dumping syndrome the day after the procedure, which is a common adverse event after a G-POEM [3].

Video 1 Gastric peroral endoscopic pyloromyotomy with clip-anchoring technique to ease the tunnel closure.

Fig. 1 Incisions for clip placement made at the beginning of the procedure.

Fig. 2 Incisions used to anchor a clip.

Fig. 3 Clip in position.

Fig. 4 Full closure of tunnel with three clips.

To our knowledge, this is the first ever case report showing the clip-anchoring technique to close a G-POEM tunnel. This technique is effective and easy. It is also cheaper than the use of over-the-scope clips recently described [4].

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• References

• 1 Gonzalez J-M, Lestelle V, Benezech A. et al. Gastric per-oral endoscopic myotomy with antropyloromyotomy in the treatment of refractory gastroparesis: clinical experience with follow-up and scintigraphic evaluation (with video). Gastrointest Endosc 2017; 85: 132-139
• 2 Inoue H, Minami H, Kobayashi Y. et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 2010; 42: 265-271
• 3 Louazon T, Rivory J, Roman S. et al. Temporary dumping syndrome after gastric peroral endoscopic myotomy: should we control the glycemia?. Endoscopy 2016; 48: E10-E11
• 4 Hernández Mondragón ÓV, Gutiérrez-Aguilar R, García 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 Espanola Enfermedades Dig Organo Of Soc Espanola Patol Dig 2020; 112: 338-342