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Recently, peroral endoscopic myotomy (POEM) has been reported to be highly effective for treating patients with achalasia [1, 2]. In achalasia, patients may have severe esophageal dilatation and thickening of the mucosal layer due to their long history of the disease. Endoclips are usually used for closure of the mucosal incision, but this can be difficult due to the thickness of the mucosal layer. Alternative methods using an Endoloop or Over-The-Scope Clip (OTSC) have been described to manage difficult mucosal incision closure [3], but these methods are complex and require sufficient skill. We present a novel technique using EndoTrac (Top Corporation, Tokyo, Japan) for mucosal incision closure in POEM. A 41-year-old man with a 10-year history of achalasia underwent POEM successfully without complications. However, we encountered difficulty in closing the incision with endoclips alone due to the extremely thick mucosal layer, so we used the EndoTrac. The EndoTrac is a novel traction device for endoscopic submucosal dissection which allows changes to the direction of traction [4, 5]. It has a line with a clinch-knotted loop, a plastic sheath, and a T-shaped handle (▶Fig. 1). A standard endoscope (GIF-Q260J; Olympus Corporation, Tokyo, Japan) was inserted with the EndoTrac running alongside the shaft of the endoscope after hooking the loop onto the jaw of the endoclip. An endoclip was deployed with the loop at the edge on each side of the mucosal incision. The T-shaped handle of the EndoTrac was then pulled, which pushed the knot towards the tip of the sheath and tightened the loop. This brought the opposing mucosal walls together and closed the mucosal incision. This procedure was repeated twice and then further standard endoclips were added to reinforce complete closure (▶Fig. 2, ▶Video 1). This novel technique of mucosal incision closure using Endotrac is highly effective and simple. We believe this is a promising technique in cases where closure is difficult with standard endoclips alone.

A novel closure technique using the EndoTrac for mucosal incision closure in peroral endoscopic myotomy