Burst Pressure of Esophageal Mucosotomy Closure in Per-Oral Endoscopic Myotomy: Running Suture Closure vs Mucosal Clip Closure.

Ashwin A Kurian, MD, Ahmed Sharata, MD, Christy M Dunst, MD, Kevin M Reavis, MD, Lee L Swanstrom, MD

Providence Portland Medical Center, Oregon Clinic- GMIS Division

Background:
Meticulous closure in esophageal surgery is mandatory due to the high morbidity associated with leaks. Endoscopic esophageal procedures such as POEM are increasing popular, and clip closure of the mucosotomy is considered standard. NOTES has lead to the development of potentially more robust closure. Endoscopic suturing is particularly appealing to surgeons as it replicates standard methods of esophageal closure. The reliability of these endoscopic techniques has not been tested. We hypothesize that endoscopic suturing will provide a more secure closure than mucosal clip closure.

Methods:
A 2 cm mucosotomy was performed in the mid-esophagus of porcine explants. A submucosal tunnel was created to the gastroesophageal junction. The myotomy of the inner circular muscle layer was performed using the standard POEM technique. The explants were divided into two groups (mucosal clip closure and suture closure). The mucosotomy was closed with standard mucosal clips placed 0.5 cm apart (total of 5 clips) in the mucosal clip closure group. A running suture closure using the Overstich tm device (Apollo Endosurgery, Austin TX) was similarly performed by placing the bites of the running suture 0.5 cm apart in the suture closure group. The ends of the esophagus were ligated and a water-perfused manometer was used to measure the intraluminal esophageal pressure, while methylene blue dyed water was infused passively into the esophagus. Burst pressure of the closed system was determined when blue dye was seen extravasating transmurally. Unpaired t-tests were used for statistical analysis. P-values less than 0.5 were considered significant.

Results:
A total of 8 porcine explants were used . They were divided into two groups (4 each). The mean burst pressure in the clip closure group were significantly higher as compared to the suture closure group (52.5mm Hg + 27 vs 11mm Hg +3; p =0.02). Although the suture closure had the lower mean burst pressure, the dye extravasation was seen predominantly from the suture needle holes, rather than from the mucosotomy itself.

Conclusions:
Clip closure of esophageal mucosotomy may be more secure than endoscopic suture closure. A surgeon should be reassured that clip closure is a reliable means of mucosotomy closure. However considering the low intraluminal pressure in the normal esophagus, suture closure may be a safe alternative. Indeed there may be clinical scenarios where clip closure may not be technically feasible (transverse mucosotomy, edematous mucosa) and therefore it may be advisable to have endoscopic suturing capability as a backup.


Session: Poster Presentation

Program Number: P230

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