Innovative fundoplication techniques in paraural endoscopic myotomy with fundoplication or POEM-F. Paraural endoscopic myotomy with fundoplication or POEM-F is a novel technique that combines natural orifice transluminal endoscopic surgery with myotomy to prevent gastroesophageal reflux disease following POEM. Following paraural endoscopic myotomy through transillumination and direct visualization, the perigastric fat and serosa overlying the gastric myotomy are carefully dissected and opened. A decompression needle is inserted through the abdominal wall to decompress the abdominal cavity during the procedure. The fundus is grasped with forceps and retracted into the tunnel to simulate the wrap. Wrap formation is continuously monitored with a pediatric gastroscope within the stomach in the retroflexed position. When the wrap is confirmed to be satisfactory, the corresponding position of the fundic serosa is marked using a cuttery-taped knife. Following creating the wrap, the primary technique for fundoplication is through attaching the endolube to the fundus and distal end of myotomy by clips. A through-the-scope clip is advanced down the channel and used to grasp the tip of the endolube device. The gastroscope and endolube catheter are then passed together into the peritoneal cavity. The endolube is secured to the gastric fundus using clips. The proximal end of the endolube is then fixed to the distal end of the myotomy with four clips, making sure that the clips are placed on the peritoneal side. The endolube is gradually tightened while the wrap is monitored with an ultra-slim gastroscope. After deploying the loop, the loop tail is trimmed and removed through the mouth. The challenges with a loop ligating device, or endoloop, include difficult passage of the device alongside the gastroscope through the esophageal mucosal incision and submucosal tunnel, complexity of handling the device, and the sharp edges of the device that could wear through the mucosal lining. To overcome these issues, we decided to use endoscopic suturing for its durability, which also provides better control over the procedure. In this technique, we used an over-the-scope suturing device. A double-channel gastroscope preloaded with the suturing device is advanced into the submucosal tunnel using the floating technique. The suturing device is entered into the peritoneum, where the marked position is located. A full thickness bite is taken from the gastric fundus on the peritoneal side. The second full-thickness bite is taken from the distal end of the myotomy. The suture is tightened and singed, forming an adequate wrap. The next technique is a suture-based fundoplication with helical anchoring. The forceps is placed through a therapeutic gastroscope and is used to grasp a suture with a T-tach. The scope is advanced to the stomach. An ultra-slim scope is advanced alongside the primary scope to the stomach. A pediatric forceps is advanced through the ultra-slim scope and the suture is grasped. The therapeutic scope is then advanced through the tunnel into the peritoneum, and a 19-gauge needle is used to puncture the stomach from the serosal side under endoscopic guidance. The needle is advanced to the lumen of the stomach. A forceps is advanced through the fine needle aspiration needle and used to grasp a suture from the ultra-slim scope. The suture is retrieved across the wall of the stomach into the peritoneum and the tunnel. Helical anchoring tags are placed over the retrieved suture and they are advanced to the submucosal tunnel. Four tags are placed at the distal end of the myotomy in the peritoneum. The suture is cinched with the T-tag located within the gastric lumen resulting in the formation of a fundoplication wrap. In conclusion, currently, the devices used for endoscopic fundoplication after POEM through the POEM-F technique are employed off-label. Suture-based techniques offer a promising alternative and could improve the long-term durability of the fundoplication wrap. Although current suturing devices have limitations such as larger diameters, a dedicated suturing device for the procedure could enhance its effectiveness.

POEM-F

fundoplication

endoscopic surgery

suture-based methods

gastroesophageal reflux