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Closure of the mucosal entry during peroral endoscopic myotomy (POEM) can be achieved using standard clips in most cases, but on rare occasions clip closure may not be possible. Alternative salvage methods for closure have been described, including the over-the-scope clip [1,2] and an endoluminal suturing device [3]. We report the first POEM case in which a fully covered stent was used to seal a mucosal incision that was difficult to close. An 83-year-old man with severe achalasia (Eckardt 9) [4] underwent POEM as described previously [5]. The esophagus was severely dilated and the mucosa was inflamed, presumably from food stasis (●" Fig.1). The inverted, friable, and edematous edges of the mucosal incision prevented adequate apposition, despite several attempts at closure using different standard clips (Resolution Clip, Boston Scientific, Natick, Massachusetts, United States; Instinct Clip, Cook Endoscopy, Winston-Salem, North Carolina, United States). In total, placement of 18 clips was attempted without success. The clips were removed and an over-thescope clip (Ovesco Endoscopy AG, Tübingen, Germany)was deployed, approximating three-quarters of the incision. HowFig.1 Achalasia with a dilated esophagus. a Esophagogastroduodenoscopy revealed food retention in a dilated esophagus. b Timed barium esophagram showed delayed esophageal emptying of oral contrast at 10 minutes in the severely dilated tortuous esophagus. Fig.2 Stent placement. a Successful deployment of the fully covered esophageal stent completely bridged the mucosal incision. b Chest radiograph on postoperative Day 1 revealed appropriate placement of the esophageal stent in the mid-esophagus. Cases and Techniques Library (CTL) E467

Successful placement of a fully covered esophageal stent to bridge a difficult-to-close mucosal incision during peroral endoscopic myotomy