Current applications of endoscopic suturing

Figure 5 Closure of per oral endoscopic myotomy tunnel orifice with endoscopic suturing device. A: Closure of peroral endoscopic myotomy (POEM) tunnel orifice in a posterior POEM with the tunnel opening at the 5 o’ clock position; B, C: We use a single running suture for closure starting at the distal, left margin of the defect as shown here. We attempt to penetrate mucosa and submucosa but not muscularis propria to avoid ischemia and pain or even possible injury to mediastinal structures; D: We proceed with suture placement through the right margin of the defect which is accomplished by torquing the endoscope as shown here; E: It is important to avoid having the running suture (here held by the needle onto the needle transfer catheter prior to loading it onto the needle driver) cross over the long suture leading to the start of the suture line which would then result in inability to properly deploy the cinch to the start or the suture line; F: The single running suture has been completed and has approximated the edges of the defect and the needle has been dropped in order to serve as a T-tag securing the suture at the proximal end of the defect; G, H: The cinch catheter is inserted over the long suture leading to the start of the running suture in the distal end of the defect, the suture is tightened and the cinch is deployed securing the suture at the start of the suture line in the distal end of the defect.