Closure methods in submucosal endoscopy

Dr. KumbhariVivek Kumbhari, MD, FRACP from Johns Hopkins Medical Institutions in Baltimore, Maryland, USA shares this video case “Closure methods in submucosal endoscopy” from the VideoGIE section.

In this video, we demonstrate various techniques that can be used to close the mucosal entry as well as an inadvertant mucosotomy during submucosal endoscopy. Endoscopic clips are widely available and are commonly used as first-line therapy. Recently, a transoral flexible endoscopic suturing device has been used to close the mucosal entry as well as a large inadvertant mucosotomy. We also demonstrate salvage techniques that are employed when first-line therapies fail such as the over-the-scope clip (OTSC) and fully covered self expandable metallic stents (FCSEMSs).

Submucosal endoscopy requires transforming the submucosal layer into an endoscopic working space to allow safe access to the muscularis propria and beyond. The submucosal tunnel places the mucosal incision proximal to the area of interest, thereby simplifying closure to merely mucosal apposition. Reliable closure of mucosal incision and inadvertent mucosotomy during submucosal endoscopy is paramount in preventing leakage of esophageal contents into the mediastinal and peritoneal spaces.

Endoscopists must recognize that there are many potential methods to close the mucosal entry during POEM. If one method fails then another should be employed. Also, if necessary, combination therapies can be safely used.

Those performing submucosal endoscopy should be armed with the capability to close large inadvertant mucosal defects. It is not only the operator who must be familiar with these techniques but also the nursing staff that are assisting during the procedure. It should be noted that the OTSCs can be difficult to remove and should not be used first-line as re-entry into the tunnel can be challenging if necessary (manage bleeding within the tunnel, etc.) Esophageal stents should also only be used as salvage therapy as they have potential to cause necrosis of the relatively devasculaized mucosa.

Watch the video here:

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