Endoscopic Suturing Research Articles

Assessing Endoscopic Suture Performance of Gynecology and Obstetrics Residents Following Methodic Training.

To evaluate the performance of residents in gynecology and obstetrics before and after practicing laparoscopic sutures, to establish when the training shows the best results, in addition to comparing whether being in different years of residency influences this progression. A prospective cohort study involving 32 medical residents evaluated with a pretest to establish their previous knowledge in laparoscopic suture. This test consisted of knotting two wires, one made of polypropylene and the other of polyglactin, with a blocking sequence of five semi-knots. We set a 30-minute limit to complete the task. Then, the residents held four training meetings, focusing on suture, Gladiator rule, knot, and symmetries, in addition to executing blocking sequences. A second test to establish progress was performed. Regarding the time spent to make the stiches using polyglactin wire, a statistically significant time improvement (p < 0.01) was observed, with a 10.67-minute pretraining median (mean 12.24 minutes) and a 2.53-minute posttraining median (mean 3.25 minutes). Regarding the stitches with polypropylene wire, a statistically significant time improvement (p < 0.05) was also observed, with a 9.38-minute pretraining median (mean 15.43 minutes) and a 3.65-minute posttraining median (mean 4.54 minutes). A total of 64.2% of the residents had been able to make the knot with polypropylene previously. One hundred percent were able to complete the task in the posttest. Model training using the Gladiator rule for laparoscopic suture improves the knotting time with statistically similar performance, regardless of the year of residency, after systematic training.

Priority Manual Skills Required when Training Future Surgeons

To increase the effectiveness of teaching manual surgical skills, we identified surgical techniques, the mastery of which allows us to develop the widest possible range of skills. These included intestinal, vascular and intracorporeal endoscopic sutures. The training was carried out on the basis of the Department of Faculty of Surgery No. 2 and the Federal Accreditation Center of Academician E. A. Wagner Perm State Medical University. The operations were performed using biological preparations. 14 students were trained in these skills. Training in the three leading manual skills allowed students to raise their skills to a high level.

Inexpensive and Easy to Set Up Robotic Cardiac Simulator Offers "Unlimited" Endoscopic Coronary Artery Bypass Grafting Experience: Proof of Concept.

Robotic totally endoscopic coronary artery bypass (TECAB) grafting is the least invasive form of coronary bypass surgery. However, despite its advantages, this approach has not gained widespread adoption. One possible reason is the advanced and complex robotic skills required to execute a totally endoscopic sutured coronary anastomosis. We prepared a novel, inexpensive, easy to set up robotic TECAB simulator. A pig heart was placed in a cardboard box, and 3 holes were made on the side to mimic the exposure and surgical ergonomics of TECAB port placement. Four robotic ports were placed and docked to the da Vinci Si robot (Intuitive Surgical, Sunnyvale, CA, USA). Monofilament 7:0 suture (7 cm long) was used to perform the anastomosis to the left anterior descending artery using remnant conduit. Seven cardiac surgeons of various training levels participated and were asked to fill out a 10-point questionnaire. The cost of the simulator totaled $20 per session, with 20 min to assemble. Each session allowed each trainee to practice 3 to 4 coronary anastomoses. Three cardiac surgeons completed the survey and strongly agreed that the model was easy to set up, the anastomotic exercise was realistic, and that this practice helped them gain confidence. Our TECAB simulator is inexpensive, easy to set up, and allows trainees to practice endoscopic coronary suturing. We believe this to be a valuable training tool to learn how to do TECAB for established surgeons and that such a simulator may be of great value to cardiothoracic training programs and their trainees. Further studies are warranted.

Management of a large percutaneous endoscopic gastrostomy tube-associated gastric ulcer with endoscopic suturing.

Management of a large percutaneous endoscopic gastrostomy tube-associated gastric ulcer with endoscopic suturing.

Endoscopic Resection with One-Port Placement: A Newly Developed Technique for the Safe Management of Advanced Endoscopic Resection for Gastric Gastrointestinal Stromal Tumors

Introduction: Endoscopic full-thickness resection (EFTR) without laparoscopic assistance (pure EFTR) is an emerging, less invasive treatment for gastrointestinal stromal tumors (GISTs). However, the technique has seldom been performed outside China because of concerns regarding pneumoperitoneum, maintenance of endoscopic view, and endoscopic suturing. This study aimed to evaluate the efficacy and safety of endoscopic resection with one-port placement (EROPP) for gastric GISTs. Methods: This retrospective study included 17 patients with gastric GISTs originating from the muscularis propria who underwent EROPP between 2019 and 2022. One camera port was inserted in the umbilicus before initiating the endoscopic procedure to maintain intra-abdominal pressure, which was monitored and adjusted via this port. While allowing for conversion to laparoscopic surgery if needed, EFTR was performed as follows: (1) circumferential incision of the mucosal and submucosal layers around the lesion was performed by typical endoscopic submucosal dissection; (2) an intentional perforation and subsequent seromuscular resection was made using dental floss and an endo-clip for traction; and (3) closure of the gastric full-thickness defect was performed with an over-the-scope clip (OTSC) after peroral retrieval of the specimen. We retrospectively assessed the short-term outcomes and safety. Results: All procedures were completed successfully without conversion to laparoscopic surgery. The median size of the resected tumors was 23 mm (range, 8–35 mm), the median resection time was 36 min (range, 22–95 min), and closure time was 18 min (range, 10–45 min). The rates of en bloc and complete resection were 100% and 88%, respectively. In 2 cases, another port was added to aspirate the leaking fluid or check the condition of the endoscopic closure. All gastric defects were endoscopically closed, mainly using OTSCs. The recovery course for all patients was uneventful, and no adverse events were reported. Conclusions: EROPP is a safe and minimally invasive treatment for gastric GISTs and appears to be suitable for introducing EFTR procedures.

Evaluation of a Clinical Outcome of Resistant Gastroesophageal Reflux Disease after Treatment with Full Thickness Endoscopic Device

Abstract Background Gastroesophageal reflux disease (GERD) is one of the most prevalent gastric disorders, defined as a condition in which reflux of gastric and duodenal contents back into esophagus causing troublesome symptoms and complications impairing quality of life. Objective To evaluate clinical efficacy of endosural suturing using gastroscope for patients with resistant GERD. Subjects and Methods This study is a prospective study. This study was carried out at Gastroenterology outpatient's clinic, endoscopic center of Ain Shams University Hospitals. The study was performed from September 2019 to December 2020. 25 adult patients having resistant GERD or Hiatus hernia. Results In our results we found that there was highly statistically significant difference according to symptoms grade between before treatment and after treatment. In our study we cleared that according to CBC, the mean of Hb 12.89 (± 0.80 SD), the mean of RDW 13.40 (±0.95 SD), the mean of platelets (*1000) 239.76 (± 60.37 SD), mean of RBCs 5.19 (± 0.51 SD). In study in our hands we found that there is highly statistically significant according to hill grade between before treatment and after treatment. Conclusion Our study has shown that endoscopic suturing of the gastroesophageal junction has significant improvements in reflux control that is sustained to 6 months and significant improvement in quality of life after procedure and significant reduction in symptoms severity after procedure.

Two endoscopic suturing techniques for the prevention of percutaneous gastrojejunostomy tube retrograde migration

Video 1Two suturing techniques for the fixation of percutaneous gastrojejunostomy tubes.

The value of single-channel endoscopic traction and kiss suture technique in closing wounds caused by endoscopic resection of gastrointestinal muscularis propria tumors.

To investigate the value of single forceps endoscopic traction stapling suture technique (SFETSST) in closing wounds caused by endoscopic resection of gastrointestinal muscularis propria tumor (GMPT). Consecutive patients who underwent submucosal tumor excavation (ESE) and endoscopic full-thickness resection (EFR) for GMPT in the Second Affiliated Hospital of Xiamen Medical College from January 2015 to January 2022 were retrospectively collected. They were divided into the SFETSST group and the standard group (patients who receive single forceps traction-free endoscopic suture technique). The healing effects were compared between the two groups. Seventy-seven patients were included in our study with 50 patients included in SFETSST group. The baseline characteristics had no significant difference between the two groups. The technical success rate of wound suture in SFETSST cluster was significantly upper than that within standard cluster (100% vs. 88.89%, P = 0.04). The wound suture time in SFETSST cluster was significantly lower than that within standard cluster (33.19 ± 10.64min, P < 0.001). Moreover, the incidence rates of intra-operative and postoperative complications in SFETSST cluster were lower than standard cluster (0 vs. 7.41%, P = 0.051 and 0 vs. 11.11%, P = 0.016). Interestingly, the SFETSST cluster had lower cost of consumables (2485.40 ± 591.78 vs. 4098.52 ± 1903.06 Yuan, P = 0.01) and shorter hospital stay (4.96 ± 0.90 vs. 7.19 ± 2.45, P < 0.001) than standard cluster. Our study showed that to fully closure the full-thickness defects of digestive tract, SFETSST was effective, safe, and economical, which was worth popularizing.

Development of a novel endoscopic suturing simulator: validation and impact on clinical learning curve (with video)

Background and AimsEndoscopic suturing is a complex skill with broad applications. This study aims to develop and validate a novel endoscopic suturing simulator and scoring system for the pursestring suture pattern. MethodsThis was a prospective study of an endoscopic suturing simulator, which consists of a circular opening representing a dilated gastrojejunal anastomosis of Roux-en-Y gastric bypass with 12 small target holes around its circumference. Pursestring suturing is performed in a counterclockwise fashion. Time allotted is 5 minutes. Each successful bite is awarded 10 points. Participants were divided into the novice, intermediate and experienced groups. Validity evidence based on content, validity evidence based on other variables and validity evidence based on consequences of testing were assessed. Results17 subjects (3 novice, 7 intermediate and 7 experienced) participated in the study. Validity evidence based on content: The content validity index for realism, relevance and representativeness was 0.89, 1.00 and 1.00, respectively. Validity evidence based on other variables: The novice, intermediate and experienced groups scored 30.0±8.2, 57.1±28.1 and 131.2±51.7, respectively (p=0.001). Validity evidence based on consequences of testing: The simulator group required 5±5 transoral outlet reduction cases before being able to independently complete an entire pursestring, while the non-simulator group required 38±11 clinical cases (p<0.0001). ConclusionThis novel endoscopic suturing simulator appears realistic, relevant and representative of the clinical suturing experience. Additionally, it appears effective at objectively assessing suturing skills and shortening the clinical learning curve.

Assessment and Techniques for Endoscopic Closure.

Endoscopic closure is an essential technique to perform safe advanced endoscopy. Without appropriate closure of a defect, patients can experience spillage of fecal contents into the peritoneal cavity resulting in abdominal sepsis. The essential components to performing endoscopic closure are assessing the defect appropriately and choosing the correct closure technique. Assessing the defect involves five separate elements: timing, size, depth, shape, blood flow, and location in the colon or rectum. Understanding how each of these elements contributes toward a successful closure allows an endoscopist to choose the proper technique for closure. There have been many types of closure techniques described in the literature but the most common are through the scope clips, over the scope clips, and endoscopic suturing. There are advantages and disadvantages of each of these closure techniques. In this manuscript, we will discuss these common techniques as well as some additional techniques and the situations where they can be employed.

Endoscopic Suture With Chemocauterization: An Effective Treatment of Congenital Pyriform Sinus Fistula.

Endoscopic cauterization is an effective method for treating pyriform sinus fistula (PSF). However, these approaches sometimes result in a higher failure rate. We present an effective technique utilizing suture combined with chemocauterization as first-line treatment in patients with PSF and evaluate the safety and efficacy of its use in 126 patients. Retrospective study. Tertiary referral center. Retrospective case review of patients treated between March 2012 and June 2021 at our institution with descriptive statistical analysis. A total of 126 patients with PSF were included in this study with a mean age of 14.7 years. There was no sex predilection. The majority of patients presented with a left-sided neck lesion (89.7%). Ten patients presented following prior attempts at the surgery of the PSF at another institution; 8 via open surgery and 2 following endoscopic CO2 laser cauterization; other patients only had a history of repeat incision and drainageor antibiotic treatment. The success rate of obliteration of the internal opening was 96.83% after a single treatment without complications. Following reoperation, a successful outcome was achieved in the remaining 4 patients. Length of stay ranged from 10 to 14 days. No recurrences occurred within 12 to 120 months followed-up. Endoscopic suture combined with chemocauterization is a safe and effective treatment of PSF. Surgery can be performed during the acute cervical inflammatory period without increased risk of complication or recurrence, however, patients found to have acute changes affecting the pyriform sinus should be treated with a staged surgery strategy.

Effect of Transoral Outlet Reduction on Hepatic Fibrosis in Roux-en-Y Gastric Bypass Patients with Weight Regain and Non-alcoholic Fatty Liver Disease.

Weight regain after Roux-en-Y gastric bypass (RYGB) is associated with worsening of liver outcomes. However, the effect of transoral outlet reduction (TORe) on liver fibrosis in RYGB patients with weight regain and possible advanced fibrosis remains unknown. This was a retrospective analysis of prospectively collected data of RYGB patients who underwent TORe for weight regain. Only patients with possible advanced fibrosis were included. TORe was performed using either an endoscopic suturing device (S-TORe) or plication device (P-TORe) to reduce the gastrojejunal anastomosis (GJA) and pouch sizes. Primary outcomes included changes in non-invasive tests (NITs) for fibrosis at 6-12months. Secondary outcomes included weight loss and changes in insulin resistance and lipid profile at 6-12months. Fifty RYGB patients were included. Baseline age and BMI were 55 ± 11years and 40.1 ± 7.3kg/m2. Baseline GJA and pouch sizes were 20 ± 7mm and 5 ± 2cm, respectively. Thirty patients (60%) underwent S-TORe and 20 patients (40%) underwent P-TORe. At 12months following TORe, there were statistically significant improvements in NITs for fibrosis, including ALT, AST and FIB-4. There was a trend towards significant improvement in liver stiffness measurement on transient elastography. Patients experienced 8.8 ± 11.2% total weight loss (TWL) (p < 0.0001), with 60% experiencing at least 10% TWL. Additionally, there was a significant improvement in HbA1c and a trend toward significant improvement in Homeostatic Model Assessment for Insulin Resistance (HOMA-IR), suggestive of improved insulin sensitivity. TORe is associated with an improvement in hepatic fibrosis in patients with NAFLD and possible advanced fibrosis.

Endoscopic tissue approximation in clinical practice and the OverStitch device: a narrative review.

The current article describes modern endoscopic technologies that allow for advanced endoscopic tissue approximation and suturing. These technologies include such devices as through the scope and over the scope clips, endoscopic suturing OverStitch device and through the scope suturing X-Tack device. Since the original introduction of the diagnostic endoscopy, progress in the field has been astonishing. Over the past several decades endoscopy has made numerous advancements allowing for a minimally invasive mechanism to treat life threatening conditions such as gastrointestinal (GI) bleeding, full thickness injuries, as well as chronic medical conditions such as morbid obesity and achalasia. A narrative review of all relevant and available literature on endoscopic tissue approximation devices over the last 15 years ago was conducted. Multiple new devices, including endoscopic clips and endoscopic suturing devices, have been developed for endoscopic tissue approximation that allow advanced endoscopic management of a wide variety of GI tract conditions. It is critical for practicing surgeons to actively participate in the development and use of these new technologies and devices in order to maintain leadership in the field, hone expertise, and to drive innovation. Further research in minimally invasive applications for these devices is needed as they continue to be refined. This article provides a general overview of the devices available and their clinical applications.

Defect closure with endoscopic suturing improves endoscopic full-thickness resection of duodenal gastrointestinal stromal tumors.

Defect closure with endoscopic suturing improves endoscopic full-thickness resection of duodenal gastrointestinal stromal tumors.

Understanding and Managing Hepatic Disease, Portal Hypertension and Stomal Varices

Scarring (cirrhosis) from advanced liver diseases can block normal hepatic circulation of blood through the liver, causing increased pressure in the venous portal system (portal hypertension). This can result in pressurised veins (varices), usually in the gastro-oesophageal region, which are liable to bleed. Variceal bleeding is dangerous, leading to haemodynamic destabilisation and death, and thus requires emergency intervention. Treatments include medications and endoscopic suturing, sclerotherapy, ligation or embolisation. Transjugular intrahepatic portosystemic shunt (TIPS) is a high-risk option that can relieve the underlying portal hypertension. People with a stoma and cirrhosis may develop peristomal varices (caput medusae), which are at risk of copious bleeding. These require immediate treatment, followed by the stoma care nurse reconsidering the stoma management routine and appliance use to reduce the risk of rebleeding.

Application of endoscopic suturing instrument in laparoscopic gastrojejunostomy

Objective: To investigate the safety and feasibility of using an endoscopic suturing instrument in laparoscopic gastrojejunostomy. Methods: A descriptive case series study was conducted to retrospectively analyze the clinical data of 5 patients with gastric cancer who underwent laparoscopic distal gastrectomy (Billroth II + Braun anastomosis) at Tangdu Hospital, Air Force Medical University from October 2022 to January 2023. The common opening was closed using an endoscopic suturing instrument. The indications were as follows: (1) patients aged between 18 and 80 years; (2) patients with gastric adenocarcinoma; (3) cTNM between I-III; (4) lower-third gastric cancer and radical gastrectomy is recommended; (5) no history of upper abdominal surgery (except for laparoscopic cholecystectomy). The surgery was performed as follows: A side-to-side gastrojejunostomy was performed with endoscopic linear cutter stapler. Then the common opening was closed with endoscopic suturing instrument. During suturing and closing the common opening, a vertical mattress suture was used to completely invert and close the mucosa-to-mucosa and serosa-to-serosa of the gastric and jejunum walls. After the first layer of suture was completed, the seromuscular layer was sutured from top to bottom to embed the common opening of stomach and jejunum. Results: Laparoscopic closure of the common gastrojejunal opening with endoscopic suturing instrument was successfully completed in all 5 patients. The operative time was (308.6±22.6) minutes, while the time of gastrojejunostomy was (15.4±3.1) minutes. The operative blood loss was (34.0±10.8) ml. No intraoperative or postoperative complications occurred in any of the patients. The first passage of gas occurred at (2.6±0.9) days, and the postoperative hospital stay was (7.0±1.9) days. Conclusion: The application of endoscopic suturing instrument in laparoscopic gastrojejunostomy is safe and feasible.

Hand-sewn esophagojejunostomy in transthoracic single-port assisted laparoscopic esophagogastrectomy for Siewert type II adenocarcinoma of the esophagogastric junction with esophageal invasion &gt; 3 cm

An optimal method for digestive tract reconstruction (DTR) in laparoscopic radical resection of Siewert type II adenocarcinoma of esophagogastric junction (AEG) has not yet been standardized. The aim of this study was to evaluate the safety and feasibility of a hand-sewn esophagojejunostomy (EJ) technique during transthoracic single-port assisted laparoscopic esophagogastrectomy (TSLE) for Siewert type II AEG with esophageal invasion > 3cm. The perioperative clinical data and short-term outcomes for patients who underwent TSLE using hand-sewn EJ for Siewert type IIAEG with esophageal invasion > 3cm between March 2019 and April 2022 have been retrospectively reviewed. A total of 25 patients were eligible. All 25 patients were successfully operated. None was converted to open surgery or mortality. 84.00% of patients were male and 16.00% were female. The mean age, body mass index (BMI), and the American Society of Anesthesiologists (ASA) score were 67.88 ± 8.10years, 21.30 ± 2.80kg/m2, and 2.08, respectively. The average incorporated operative and hand-sewn EJ procedural times were 274.92 ± 57.46 and 23.36 ± 3.00min, respectively. The length of extracorporeal esophageal involvement and proximal margin was 3.31 ± 0.26cm and 3.12 ± 0.12cm, respectively. The average time for the first oral feeding and hospital stay were 6 (3-14) and 7 (3-18) days, respectively. Two patients (8.00%) developed postoperative grade IIIa complications according to the Clavien-Dindo classification, including 1 case of pleural effusion and 1 case of anastomotic leakage, both of whom were cured by puncture drainage. Hand-sewn EJ in TSLE is safe and feasible for Siewert type II AEG. This method can ensure safe proximal margins and could be a good option with an advanced endoscopic suture technique for type II tumor with esophageal invasion > 3cm.

Transoral Outlet Reduction to Tackle Weight Regain After Roux-en-Y Gastric Bypass: a Single Center Initial Experience.

Long-term failure after Roux-en-Y gastric bypass (RYGB) is well known and occurs in 10-15% of patients according to the literature. Causes are multifactorial and dilatation of the gastro-jejunal anastomosis (GJA) is only one of these. A transoral outlet reduction (TORe) with endoscopic sutures to reinstall more restriction could be a valid and safe alternative to reduce regained weight after failed gastric bypass surgery. The objective of this article is to describe our single-center experience and discuss the adverse events of the technique. To describe our single-center case series and adverse events after TORe for weight regain after RYGB. We report a case series of 20 patients referred due to weight regain after RYGB with a dilated GJA. TORe was performed using an endoscopic full-thickness suture device (Apollo OverStitch®) to reduce the diameter of the GJA and the volume of the gastric reservoir. Prospectively collected data on technical feasibility, safety and efficacy are described with a median follow-up of 22 (6-38) months. Mean BMI was 44.5kg/m2 at the time of RYGB. Postoperative nadir BMI was 27,7kg/m2. The average time to TORe was 12.1years after initial RYGB. Patients regained a mean 45.9% of excess body weight loss (EWL) before TORe and had a mean preprocedural BMI of 35.3kg/m2. The aim was to reduce the aperture of the GJA to 5mm which was done with a mean of 1.7 sutures and 3.5 stitches. The mean absolute weight loss was 13kg and BMI reduction was 3.9kg/m2 after 6months. After a median follow-up of 22months, a BMI of 31.4kg/m2 was observed. Dumping symptoms resolved in four of our patients 6weeks after TORe. Procedural adverse events were nausea and vomiting, sore throat, mild transient abdominal pain, diarrhea and constipation. All of them were treated conservatively. Due to a lack of weight loss, a suture failure was assumed in two of our patients. We describe one case of postprocedural mediastinitis, presumably due to a distal esophageal perforation, treated with a laparoscopic drainage without clinical evidence for perforation. Endoscopic TORe by narrowing the dilated GJA appears to be an efficient and safe minimal invasive option to tackle weight regain after RYGB and should be more used in clinical practice.

Safety and efficacy of a novel suturing device for closure of large defects after endoscopic submucosal dissection (with video)

Endoscopic suturing (OverStitchTM) enables full closure of large defects post endoscopic submucosal dissection (ESD). However, its use is limited by the need for double channel endoscope. A Novel closure system , OverStitchSX compatible with any single channel endoscope was introduced to address these shortcomings. The aim of this study is to assess the safety and feasibility of OverStitchSX for the closure of large defects post ESD. This is a prospective single center feasibility study of patients who underwent closure of large defects post ESD with Apollo OverStitchSX system. Main outcomes of the study included technical and clinical success, same-day discharge rate and adverse events rate . A total of 33 patients were enrolled. Mean diameter of included lesions was 5.38 ± 2.52 cm. The defect occupied ≥ 50% of the lumen circumference in 70% of the cases. En bloc resection, R0 resection, and curative resection were achieved in 97%, 87.5% and 78.8% of patients, respectively. Technical success and clinical success were seen in 93.9% and 90.9% of the cases, respectively. Same-day hospital discharge was achieved in 77.4% of patients. Total adverse events rate was 35.7%, including delayed bleeding in one patient post rectal ESD; managed conservatively, self-resolving rectal pain (n=7), rectal stricture requiring dilation (n=1) and temporary dysphagia (n=1). No immediate or delayed perforation was reported. OverStitchSX enabled safe and effective closure of large defects post ESD. Future trials are needed to determine its superiority over OverStitchTM for the closure of defects in challenging locations.

Per-Oral Plication of (Neo)Esophagus: Technical Feasibility and Early Outcomes

BackgroundEndoscopic sleeve gastroplasty is an example of endoscopic sutured plications being used to remodel a gastrointestinal organ. With per-oral plication of the esophagus (POPE), similar plications are used to remodel the dilated and redundant megaesophagus of end-stage achalasia. Redundancies and dilations can also develop in the neoesophagus of a patient with prior esophagectomy. Megaesophagus and a redundant neoesophagus can both lead to debilitating dysphagia, regurgitation, and recurrent aspiration pneumonia. Traditionally, this anatomic problem requires complex revisional or excisional surgery, to which POPE offers an incisionless alternative. MethodsThis is a dynamic manuscript with video demonstration of POPE, as well as review of five cases performed in 1 year. Data were collected in a prospectively maintained database, and the institutional review board approved retrospective review for this publication. The procedure is performed using a dual-channel upper endoscope fixed with an endoscopic suturing device, with the patient supine under general anesthesia. ResultsPOPE was technically completed in all cases with no serious complications, and patients either went home the same day or spent one night for observation. Most patients reported immediate and substantial symptomatic improvement. Objective pre- and post-measures include esophagram and nuclear gastric emptying studies. ConclusionThis article discusses early experience at one institution with POPE, with detailed description of the procedure and technical considerations. An accompanying video reviews two cases, one with megaesophagus and one with a gastric conduit. While this novel procedure has limited and rare indications, it offers a low-morbidity solution to a challenging anatomic problem that traditionally requires invasive surgery.