Suture-based fundoplication techniques during peroral endoscopic myotomy.

Background and Aims: Peroral endoscopic myotomy (POEM) with fundoplication (POEM-F) combines POEM with endoscopic fundoplication to prevent postprocedural gastroesophageal reflux. The conventional techniques using the loop-ligating device can be technically challenging, with durability issues. Endoscopic suturing may address these limitations. We describe 2 novel suture-based techniques for fundoplication after POEM. Methods: Two patients with type II achalasia underwent POEM-F using suture-based fundoplication approaches. Results: In the first case, an over-the-scope suturing system was used to place seromuscular sutures from the peritoneal side between the gastric fundus and the distal myotomy edge, creating a wrap secured with a cinch. In the second, a T-Tag suture (OverStitch 2-0 Polypropylene Suture; Boston Scientific, Marlborough, Mass, USA) was retrieved from the gastric lumen using forceps through a 19-gauge needle from the serosal side. Helical tacks were placed over the externalized suture and anchored to the peritoneum at the distal end of the myotomy. The wrap was completed by cinching the suture, with the T-Tag left in the gastric lumen. No adverse events were observed. Conclusions: Suture-based techniques for POEM-F offer a promising alternative to loop-ligating methods, potentially improving procedural control, and warrant evaluation of long-term durability. These techniques remain off-label and technically demanding but may be further optimized by the development of dedicated endoscopic suturing systems tailored for POEM-F.