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Maintaining the integrity of the mucosal flap and the reliable closure of mucosal entry during peroral endoscopic myotomy (POEM) is paramount in preventing leakage of esophageal contents into the mediastinal space. We describe our experience with POEM, the problems encountered with closure of mucosal flaps, and successful closure with over-the-scope clips (OTSC). Two patients with achalasia underwent successful endoscopic myotomy during POEM. During both procedures, the proximal end of the longitudinal mucosal incision was noted to be gaping and completion of the closure with standard clips was unsuccessful. The sides of the flap were approximated using a Twin Grasper followed by placement of OTSC. Closure of the mucosal entry appeared to be complete at the end of the procedures. Esophagram the following day revealed no leaks in either patient. There were no other complications and patients were discharged home after 1 - 2 days of hospital observation. Patients reported complete resolution of achalasia symptoms during follow-up. We propose closure of mucosal incisions during POEM using one to two OTSC as an alternative to described techniques. The use of OTSC may simplify the procedure and result in a more durable (i. e. full-thickness) closure.

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Purpose To determine alterations in bulbar conjunctival microvascular hemodynamics in sickle cell retinopathy (SCR) subjects with focal macular thinning (FMT). Methods Conjunctival microcirculation imaging and spectral domain optical coherence tomography (SD-OCT) were performed in 22 subjects (eyes) diagnosed with SCR. Based on evaluation of SD-OCT retinal thickness maps, eyes were assigned to one of two groups: with or without FMT. Conjunctival venule diameter and axial blood velocity were measured in multiple venules in each eye by customized image analysis algorithms. Measurements were then categorized into two vessel size groups (vessel size 1 and 2) and compared between FMT groups. A Pearson correlation coefficient was computed to assess the relationship between retinal thickness and axial blood velocity. Results Mean age, hematocrit, sickle cell hemoglobin type, and median retinopathy score were not significantly different between the two groups (p ≥ 0.1). Retinal thickness in parafoveal and perifoveal temporal subfields was significantly lower in eyes with FMT as compared to eyes without FMT (p ≤ 0.04). There was a significant effect of FMT on axial blood velocity (P = 0.04), while the effect of vessel size was not significant (P = 0.4). In vessel size 1, axial blood velocity was lower in eyes with FMT than in eyes without FMT (P = 0.03), while in vessel size 2, there was no statistically significant difference between FMT groups (P = 0.1). In vessel size 1, there was a significant positive correlation between axial blood velocity and retinal thickness in the perifoveal (r = 0.48, P = 0.02) and parafoveal (r = 0.43, P = 0.04) temporal subfields. Conclusion Conjunctival axial blood velocity in small venules is reduced in SCR subjects with focal macular thinning.