Closure of a mucosal entry using the clip-with-line method.

Peroral endoscopic myotomy (POEM) is a revolutionary therapy for achalasia [1,2]. Because incomplete closure of a mucosal entry may lead to severe mediastinitis after POEM, secure closure of this site is very important in clinical settings. However, unlike general surgery, endoscopic procedures are performed with one hand, and there is no countertraction of the mucosa. Therefore, slippage of clips or an inversion of mucosal entry may occur during closure, particularly when performed by beginners. To solve such clinical problems, we investigated a novel method for closure of a mucosal entry using the clip-with-line method.

First, a clip with line is left on the proximal side and another is left on the distal side of the mucosal entry. The line is pulled and mild tension is generated at the mucosal entry, which is subsequently lifted up. The clips are left from the distal to proximal sides of the mucosal entry. In this situation, precise clipping is very easy. The line is then cut after the closure of the mucosal entry (Fig. 1 A-F).

Figure 1

(A) A clip with line. (B, C) A clip-with-line is left on the proximal side and another on the distal side of the mucosal entry. The line is pulled, generating a mild tension at the mucosal entry, which is subsequently lifted up. (D, E) The clips are left from the distal to proximal sides of the mucosal entry. In this situation, precise clipping is very easy. (F) After closure of the mucosal entry, the line is cut

Using a monofilament line is favorable because it is easy to cut the line. The advantages of closure of mucosal entries using the clip-with-line method include avoidance of inversions of mucosal entries and slippage of clips, and low interindividual difference; furthermore, the technique is particularly useful for beginners. To date, several endoscopic suturing techniques during POEM have been reported [3-6]. The clip-with-line method is useful for the closure of mucosal entries and does not require specialized instrumentation compared with conventional techniques.