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Endoscopic Suturing Versus Endoclip Closure of Mucosotomy in POEM: a Case-Control Study
Radu Pescarus*, Maria a. Cassera, Eran Shlomovitz, Ahmed Sharata, Kevin M. Reavis, Christy M. Dunst, Lee L. Swanstrom
GI Surgery, Portland Providence Medical Center, Portland, OR
INTRODUCTION
Per-oral endoscopic myotomy (POEM) is establishing itself as an elegant minimally invasive treatment of achalasia. One of the crucial steps of the procedure is obtaining adequate mucosal closure. Traditionally, endoclips have been used for a secure closure but these can be difficult to apply in some situations. A recently described alternative closure is endoscopic suturing using proprietary devices. This abstracts illustrates our experience with the OverStitch endoscopic suturing device during POEM cases.
METHODS
Endoscopic suturing was used during 10 of the 105 POEM cases in our series (9.5%) for a variety of indications. In order to evaluate the efficacy and cost of this new technology, a retrospective case-control study was performed. Of the 10 cases, 5 cases were eliminated for the following reasons: in 2 cases the mucosotomy was closed with endoscopic suturing and clips, in 2 cases a concomitant inadvertent mucosotomy was also sutured, and in 1 case the closure time was not recorded. The 5 cases in which the mucosotomy was repaired with the OverStitch device were included in the study. These were matched to 5 cases in which conventional closure of the mucosotomy was obtained with clips. The matching criteria included: (1) patient age (±10 years), (2) surgery within 12 months, (3) achalasia Chicago type, and (4) achalasia pre-operative stage.
For the 5 POEM with endoscopic suturing closure and the 5 controls we collected demographic information, pre-operative achalasia type and stage, closure time, number of clips or sutures, short/long term complications, length of stay (LOS), instrument-related and operating room (OR)-related costs. Independent sample t-test and chi square were performed when appropriate.
RESULTS
The OverStitch and control group were not statistically different in terms of age (p=0.71), BMI (p=0.36), Eckardt score (p=0.5), achalasia type (p=1.0), achalasia score (p=1.0) and LOS (p=0.21). The average number of clips used was 5 (range 3-7) and the average number of figure-of-eight OverStitch sutures was 2 (range 1-3). No closure-related complications were recorded. The closure time was significantly shorter with endoclips (16±12 min) than with OverStitch (33±11 min) with a p=0.047. The total closure cost showed a trend towards lower cost with clips ($1502±849) vs. OverStitch ($2521±575) with a p=0.057.
CONCLUSION
Adequate closure of POEM mucosotomy can be obtained both with conventional endoclips and OverStitch. Overall, closure time is shorter and instrument cost is lower with endoclip closure. A caveat is that suture closure in our series was mainly used for cases where clip closure was considered to be difficult or not possible. Endoscopic suturing may therefore be best used for difficult mucosotomy closures or full-thickness perforations in which endoclip closure could be difficult, impossible or more tenuous.
| Endoclips (Average ± Standard Deviation) | OverStitch (Average ± Standard Deviation) | p-value | | Closure time (min) | 16±12 | 33±11 | 0.047 | | Instrument cost (USD) | 703±327 | 873±39 | 0.282 | | OR cost (USD) | 799±596 | 1648±548 | 0.047 | | Total cost (USD) | 1502±849 | 2521±575 | 0.057 |
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