Endoscopic suturing for closure of endoscopic submucosal dissection defects Article Swipe

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Samuel Han , Sachin Wani , Tonya Kaltenbach , Roy Soetikno , Hazem Hammad · YOU? · · 2019 · Open Access · · DOI: https://doi.org/10.1016/j.vgie.2019.04.018

Endoscopic submucosal dissection (ESD) allows for en bloc resection of tumors within the GI tract, typically leaving a large mucosal defect, which can result in postprocedure adverse events such as delayed perforation or bleeding.1Fujiya M. Tanaka K. Dokoshi T. et al.Efficacy and adverse events of EMR and endoscopic submucosal dissection for the treatment of colon neoplasms: a meta-analysis of studies comparing EMR and endoscopic submucosal dissection.Gastrointest Endosc. 2015; 81: 583-595Google Scholar Different techniques have been described for the closure of mucosal defects after ESD, including the use of a variety of clips (with or without an Endoloop or string) to close these defects, which may reduce the risk of adverse events.2Harada H. Suehiro S. Murakami D. et al.Clinical impact of prophylactic clip closure of mucosal defects after colorectal endoscopic submucosal dissection.Endosc Int Open. 2017; 5: E1165-E1171Google Scholar, 3Kato M. Ochiai Y. Fukuhara S. et al.Clinical impact of closure of the mucosal defect after duodenal endoscopic submucosal dissection.Gastrointest Endosc. 2019; 89: 87-93Google Scholar, 4Osada T. Sakamoto N. Ritsuno H. et al.Closure with clips to accelerate healing of mucosal defects caused by colorectal endoscopic submucosal dissection.Surg Endosc. 2016; 30: 4438-4444Google Scholar, 5Yahagi N. Nishizawa T. Akimoto T. et al.New endoscopic suturing method: string clip suturing method.Gastrointest Endosc. 2016; 84: 1064-1065Google Scholar Endoscopic suturing may be another method to effectively close these defects. Although these methods are not the standard of care for ESD, they represent an area of interest because of their potential in the hands of expert endoscopists to decrease adverse events such as delayed perforation and bleeding and to reduce or eliminate post-ESD hospitalization, thereby reducing costs.6Maple J.T. Abu Dayyeh B.K. Chauhan S.S. et al.Endoscopic submucosal dissection.Gastrointest Endosc. 2015; 81: 1311-1325Google Scholar, 7Draganov P.V. Wang A.Y. Othman M.O. et al.AGA Institute Clinical Practice Update: Endoscopic Submucosal Dissection in the United States.Clin Gastroenterol Hepatol. 2019; 17: 16-25.e1Google Scholar Limited data are available on the efficacy of endoscopic suturing after ESD, and no standard technique currently exists for this indication; therefore, we aimed to describe and formalize the technique of mucosal endoscopic suturing to close gastric and rectal mucosal defects created from ESD.8Kantsevoy S.V. Bitner M. Mitrakov A.A. et al.Endoscopic suturing closure of large mucosal defects after endoscopic submucosal dissection is technically feasible, fast, and eliminates the need for hospitalization (with videos).Gastrointest Endosc. 2014; 79: 503-507Google Scholar Upon completion of the ESD procedure in either the stomach or the rectum, the gastroscope was removed and a double-channel therapeutic gastroscope (Olympus, Tokyo, Japan) was loaded with the OverStitch endoscopic suturing system (Apollo Endosurgery, Austin, Tex, USA). All suturing was performed in the antegrade position. Starting with the edge most distal to the endoscope insertion site (12 o’clock), endoscopic suturing of the ESD defect was initiated. The suturing arm was closed to push the needle and suture through the mucosal and submucosal flap, as opposed to the muscle layer. As has been previously described, the needle holder was then advanced to grab the needle, and the needle holder was then pulled back to remove the needle from the suturing arm.9Kantsevoy S.V. Armengol-Miro J.R. Endoscopic suturing, an essential enabling technology for new NOTES interventions.Gastrointest Endosc Clin N Am. 2016; 26: 375-384Google Scholar The suturing arm was then opened, which freed the edge of the defect. The suturing arm was then closed, and the needle holder was advanced to place the needle back into the suturing arm. Once this initial flap was grabbed, the endoscope was then moved to the left toward the 10 o’clock position of the defect, repeating the same process of grabbing the tissue. The endoscope was then moved from left to right toward the 2 o’clock position, again grabbing the tissue. Moving then from a right to left position, the tissue at the 8 o’clock position of the defect was grabbed. We then moved from a left to right manner, grabbing the mucosa/submucosa at the 4 o’clock position. Finally, the edge of the defect at the 6 o’clock position, or position most proximal to the endoscope insertion site, was grabbed (Fig. 1). Once these 6 mucosal/submucosal flaps had been sutured together, we deployed the cinching mechanism. This technique of suturing was used to maintain visualization throughout the entire suturing process and to facilitate handling of the endoscope with the suturing system. In total, we have used this technique successfully in 14 patients, including 4 rectal lesions (Figure 2, Figure 3, Figure 4, Figure 5) and 10 gastric lesions (Figure 6, Figure 7, Figure 8, Figure 9) with a mean lesion size of 3.2 cm (standard deviation 1.9). Pathologic analysis of resection specimens identified neuroendocrine tumors (n = 2), adenocarcinomas (n = 2), tubular adenomas with high-grade dysplasia (n = 2), GI stromal tumors (n = 2), tubulovillous adenoma with high-grade dysplasia (n = 1), villous adenoma (n = 1), fibroma (n = 1), lipoma (n = 1), spindle cell neoplasm (n = 1), and intestinal metaplasia (n = 1). None of the 14 patients had any adverse events, including delayed perforation or bleeding. Furthermore, most patients were able to be discharged the same day without the need for inpatient observation. Healing of mucosal defects after endoscopic suturing did not affect endoscopic surveillance and sampling of the resection scar.Figure 3Rectal lesion after endoscopic submucosal dissection.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 4Rectal lesion defect after suturing.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 5Rectal defect healing seen on surveillance.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 6Gastric lesion.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 7Gastric lesion after endoscopic submucosal dissection.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 8Gastric lesion defect after suturing.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 9Gastric defect healing on surveillance.View Large Image Figure ViewerDownload Hi-res image Download (PPT) In summary, this video (Video 1, available online at www.VideoGIE.org) shows the step-by-step process of using endoscopic suturing for closure of a post-ESD rectal defect. Endoscopic suturing offers another effective method to close mucosal defects after rectal and gastric ESD. Future studies should examine whether closure by endoscopic suturing can help prevent adverse events such as delayed bleeding or perforation.

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Endoscopic suturing for closure of endoscopic submucosal dissection defects

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article

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2019

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2019-06-26

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Samuel Han, Sachin Wani, Tonya Kaltenbach, Roy Soetikno, Hazem Hammad

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Medicine, Endoscopic submucosal dissection, Perforation, Endoscopic mucosal resection, Surgery, Dissection (medical), CLIPS, Endoscopy, Metallurgy, Materials science, Punching

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