Through-the-scope suture closure of peroral endoscopic myotomy mucosal incision sites: not yet there

Zhang et al. reported a retrospective study using a novel through-the-scope (TTS) suture system for closure of peroral endoscopic myotomy (POEM) mucosal incision sites in 35 patients [1]. Technical success was achieved in 91.4 % of patients with a mean closure time of 12.4 minutes. However, 17 patients (53.1 %) required ≥ 2 TTS suture systems and 3 patients (8.6 %) required additional TTS clips to achieve secure mucosal closure.

POEM has emerged as a mainstream treatment option for esophageal motility disorders, with endoscopic clipping being considered the most effective and widely available method for the closure of gastrointestinal wall perforations [2] [3]. Other suturing devices/systems that have been developed for closure of gastrointestinal wall defects include over-the-scope clips (OTSC; Ovesco Endoscopy AG, Tubingen, Germany) and Overstitch (Apollo Endosurgery, Austin, TX, USA) [4]. However, these devices have not been widely used for wound closure after POEM because of limited working space.

The novel TTS procedure currently requires a longer (12 minutes) suturing time and has a lower success rate (91 %) compared with simple endoscopic clipping, which requires 4–6 minutes and has 100 % success [3] [5]. Importantly, both the overstitch and TTS devices are not available worldwide. It is also likely that TTS will be more costly than endoscopic clips. Importantly, the authors reported that a significant proportion of patients required multiple devices for secure closure, which reduces the attractiveness of the method, as single-handed endoscopic clipping can be performed without changing devices, resulting is a lower overall procedure time and less burden on the patient. While new inventions are always welcome, we believe that TTS in POEM may expose patients to longer, more complicated intervention with associated post-procedural risks (perforations, leaks etc.) that are still unclear and which ultimately contribute to the financial burden on the patient and hospital system.

Publication History

Article published online:
29 March 2023

• References

• 1 Zhang LY, Bejjani M, Ghandour B. et al. Through-the-scope suture closure of peroral endoscopic myotomy mucosal incision sites. Endoscopy 2022; DOI: 10.1055/a-1890-4917.
• 2 Bredenoord AJ. Peroral endoscopic myotomy: ready for prime time in all achalasia patients?. Endoscopy 2016; 48: 1055-1056
• 3 Zeng CY, Li GH, Zhu Y. et al. Single-channel endoscopic closure of large endoscopy-related perforations. Endoscopy 2015; 47: 735-738
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• 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