Snare-assisted clipping method for closure of mucosal incision of gastric peroral endoscopic myotomy

Abstract

Gastric peroral endoscopic myotomy (G-POEM) is an emerging treatment modality for gastroparesis. This technique involves mucosal incision, submucosal tunneling, and pyloric myotomy followed by closure of the mucosal incision.

There are multiple closure methods described in the literature, including through-the-scope (TTS) clips,¹ over-the-scope clips, and endoscopic suturing.² TTS clips are the easiest and most economical of the above methods. However, mucosal closure after G-POEM with TTS clips can by difficult due to the thicker gastric mucosa and widening of the mucosal entry site, resulting in difficulty of apposition of mucosal edges.

Clip and snare traction is well described in the literature to assist endoscopic submucosal dissection.³ An internal traction method has been previously described for full-thickness mucosal defect closure.⁴

I describe an adaptation of the above methods to assist clip deployment for mucosal closure.

Once the myotomy is complete, the scope is withdrawn and a snare is attached to the end of the scope by closing the snare over the distal attachment cap. Then the scope is reinserted and a TTS clip is closed just distal to the distal edge of the mucosal incision. Prior to full deployment of the clip, the snare is opened to disengage from the scope and closed over the stem of the clip.

The snare is then used to apply gentle traction to pull the mucosa upwards, creating a mucosal “tent.” The next clip is then deployed, closing the mucosal edges together. Another clip is then introduced through the channel and is used to transfer the snare to the stem of the last deployed clip. This process is repeated until the mucosal incision is completely closed. In this case, the final clip is deployed without the assistance of the snare.

This case illustrates a novel method of gastric mucosal incision closure using inexpensive, widely available devices.

Author declares no conflict of interest for this article.

Approval of the research protocol by an Institutional Review Board: N/A.

Informed consent: Informed consent was obtained from the patient to publish deidentified endoscopic images and videos.

Registry and the registration no. of the study/trial: N/A.

Animal studies: N/A.