Through the scope suturing for closure of a contained leak after cricopharyngeal peroral endoscopic myotomy. Cricopharyngeal bar peroral endoscopic myotomy is a safe and effective treatment for cricopharyngeal bar dysphagia. Persistent leaks after CPPOM are a rare complication. Closure of mucosal defects in the proximal esophagus and upper esophageal sphincter can be technically challenging with existing tools. Endoscopic suturing with a novel through-the-scope suturing system can overcome some of these challenges. A 69-year-old female with past medical history of GERD presents with progressive dysphagia to solids. An initial barium esophagram demonstrated narrowing of the cervical esophagus, suggestive of a prominent cricopharyngeal bar. Based on her symptoms and imaging, we decided to proceed with a diagnostic EGD and possible CPPOM. On initial endoscopy, a prominent cricopharyngeal bar was present at 18 cm from the incisors. Submucosal injection and mucosal incision were performed proximal to the cricopharyngeal bar at 15 cm. Submucosal tunneling began at the level of the incision and extended for a total of 5 cm. A thickness myotomy was performed with the insulated tip knife to the base of the tunnel. The mucosal incision can be seen here. It is our current practice to close these defects with through-the-scope clips. This mucosal incision was closed with a total of 5 through-the-scope clips. An esophagram was performed on post-operative day 1. The yellow arrow highlights a persistent esophageal posterior defect and collection of contrast at the level of C7 to T1. This posterior fluid collection is further demonstrated on the coronal view of the esophagram. The leak was managed conservatively by maintenance of NPO status and continuation of IV nutrition and antibiotics. A CT was performed on post-operative day 10, and the yellow arrow again highlights a persistent leak and pre-vertebral collection of air and fluid. Given her persistent dysphagia, odynophagia, and CT findings despite conservative management, a repeat endoscopy was performed on post-operative day 13. A persistent mucosal defect is seen here. Note the irregular borders and significant edema and inflammation. Given the limited working space in the proximal esophagus, the irregular borders, and size of the defect, we decided to use a through-the-scope suture system to approximate the mucosa. This novel endoscopic tool is a suture-based device that consists of four 5mm steel tacks strong on a 3O propylene suture. The suture runs through an eyelet on all four tacks, and each tack is advanced one by one along the suture and deployed on the target tissue. We plan to deploy the tacks in the following Z pattern. Once good contact is made with the mucosa, the first tack is driven into place and deployed. A second tack is placed on the opposite border of the distal aspect of the defect. Note again that good contact is made between the tack and the tissue, and the tack is then driven into place. Here, a tach is placed at the proximal aspect of the defect. Based on the size and character of the defect, a total of 6 tachs from 2 suture systems were used to achieve adequate closure. Note here that the suture can be pre-cinched to assess mucosal approximation prior to placement of subsequent tachs or the final cinch. After the mucosa is adequately approximated, a cinch is deployed to cut the suture and secure the system. After continued nutritional support and IV antibiotics, a nosophogram was performed on post-operative day 24. There is no longer a nosophageal leak. The yellow arrow here highlights the tachs in the proximal esophagus. The patient reported significant improvement in dysphagia and adenophagia. However, she did report persistent globus sensation, which was attributed to the tachs of the suturing system. A repeat endoscopy was performed and showed the tachs in place in the proximal esophagus. Note that the majority of the tachs were no longer embedded in the mucosa. The decision was made to perform a superficial mucosectomy with a 10-millimeter snare with electrocautery on endocut Q setting. After a successful mucosectomy, inspection of the defect showed no evidence of deep injury or bleeding. The patient went on to have complete resolution of her globus sensation. She developed mild dysphagia and white plaques seen on direct laryngoscopy four weeks after the procedure, which subsequently improved with oral nystatin. In conclusion, persistent leaks are a rare complication of CP-POM. Defect characteristics and limited working space can make closure technically challenging in the proximal esophagus. However, through-the-scope suturing can overcome these challenges and is an effective tool for closure of partial thickness defects.

through-the-scope suturing

contained leak closure

cricopharyngeal peroral endoscopic myotomy

mucosal defect closure

novel suturing system