P2751 - Through the Scope Suture Mucosal Closure During Peroral Endoscopic Myotomy

Tuesday, October 26, 2021

10:30 AM – 4:00 PM PT

Location: Shoreline Exhibit Hall

Has Audio

Presenting Author(s)

Linda Y. Zhang, MBBS

Johns Hopkins Medical Institutes
Baltimore, MD, United States

Linda Y. Zhang, MBBS, Mouen A. Khashab, MD
Johns Hopkins Medical Institutes, Baltimore, MD

Introduction: Secure mucosal closure is vital during peroral endoscopic myotomy (POEM) and is traditionally achieved using through the scope clips (TTSC). X-Tack (Apollo Endosurgery, Austin, Texas) is a novel through the scope suture (TTSS) system, comprising of four individual tacks prestrung on a 3-0 polypropylene suture. We present our early experience of POEM closure with TTSS.

Methods: We analyzed all patients who underwent POEM with TTSS closure between February-June 2021 at a single tertiary endoscopy unit. During the study period, TTSS was used first line for closure, with any adjunctive devices being at the discretion of the endoscopist. The remainder of the procedure and follow up was per institutional standard of care. Primary outcome was technical success (complete closure using TTSS without requiring adjuncts). Secondary outcomes included clinical success (Eckhardt score ≤3), adverse events (AEs, per ASGE lexicon) and procedure time (scope entry to final removal). Continuous variables are presented as mean (standard deviation).

Results: 34 patients (age 58.1 (16.2), female 18 (53%)) underwent POEM with TTSS mucosal closure (Figure 1). Eleven patients (32.4%) were on antithrombotic therapy and six patients had prior achalasia treatment. Mucosal incisions were securely closed with TTSS in 31 cases (92%) (Table 1). Of these, more than one TTSS system was required in 16 cases (51.6%). The remaining three patients also required 1-5 TTSC for secure mucosal closure. The majority of patients were discharged same day (22 of 32 outpatients, 68.8%). Ten patients were admitted post-POEM due to pain/nausea (n=4), comorbidities (n=4), or procedural concerns (n=2) with a mean length of stay of 1.9 (1.2) days. There were no AEs, specifically no leaks, mucosal dehiscence, need for repeat endoscopy or unexpected representations/readmissions. Clinical success was achieved in 21 of 23 evaluable patients (91.3%) with >2 weeks follow up post-POEM.

Discussion: TTSS achieved secure mucosal closure following POEM in the majority of cases without increasing procedure time or AEs but required more than one system in >50% of cases. Despite our promising outcomes, we believe further studies and possible device modification, for example an increase in included tacks, is warranted to achieve a greater number of mucosal closures with one system. This would further reduce procedural costs and time, allowing TTSS to truly be a strong contender for routine use in POEM closure.

Figure: Figure 1 Through the scope suture closure of mucosal incision for peroral endoscopic myotomy (POEM) (a) Mucosal incision site (b) First tack placed inferolateral to defect, leaving a generous margin of normal mucosa (c) All four tacks are placed in a "Z" pattern around the defect (d) Defect completely closed following approximation of tacks and cinching of suture

Characteristic	Outcome
Indication, n (%) Achalasia Type I Type II Type III Esophagogastric junction outlet obstruction Jackhammer esophagus	25 (73.5%) 2 17 6 6 (17.6%) 3 (8.8%)
Peroral endoscopic myotomy (POEM) approach, n (%) Anterior Posterior	32 (94.1%) 2 (5.9%)
Mucosal incision length, mean (SD), cm	1.94 (0.16)
Tunnel length, mean (SD), cm	13.38 (2.7)
Myotomy length, mean (SD), cm Esophageal Gastric	7.71 (2.6) 2.94 (0.3)
Distensibility index at 40 mls, mean (SD), mm²/mmHg Pre-POEM Post-POEM	1.29 (1.1) 4.80 (1.3)
Procedure time, mean (SD), minutes	49.76 (11.1)
Post-procedure admission, n (%) (in outpatients, n=32) Pain/nausea Comorbidities Procedural concern	10 (31.3%) 4 4 2
Eckhardt score, mean (SD) Pre-POEM Post-POEM	6.44 (2.9) 0.91 ( 1.3)
Technical success, n (%) One system Two systems Three systems	31 (91.2%) 15 15 1*
Clinical success, n (%) (in 23 evaluable patients)	21 (91.3%)

Table: Table 1 Outcomes

*Suture snapped during cinching of second system

Disclosures:

Linda Zhang indicated no relevant financial relationships.

Mouen Khashab: Apollo Endosurgery – Consultant. Boston Scientific – Consultant. GI Supply – Consultant. Medtronic – Consultant. Olympus – Consultant.

Linda Y. Zhang, MBBS, Mouen A. Khashab, MD. P2751 - Through the Scope Suture Mucosal Closure During Peroral Endoscopic Myotomy, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.