Purse-string sutures using novel endoloops and repositionable clips for the closure of large iatrogenic duodenal perforations with single-channel endoscope: a multicenter study

How to close mucosal incisions?

This article provides an overview of the techniques for closure of the mucosal entry point following advanced procedures in the third space. The outbreak of natural orifice transluminal endoscopic surgery (NOTES) has significantly impacted the treatment of various benign and malignant conditions. Reliable and secure closure of the mucosal entrance is essential for avoiding serious adverse events. Although small defects are typically closed using through-the-scope clips (TTSCs) or over-the-scope clips (OTSCs), challenges may occur with larger or transmural defects. Alternative methods, such as specialised stitches and full-thickness suturing systems, have been developed to address these challenges with promising results. Each method has its own pros and cons, and the choice of closure technique depends on various factors such as anatomical location, endoscopist expertise, costs, and clinical context. By understanding the technical specifications of each closure device, endoscopists can make decisions that enhance patient outcomes and minimise the risk of complications associated with the approximation of defect edges. Continued research is essential to optimise the evolution of newer closure devices and techniques for advancing NOTES.

Endoscopic suturing and clipping devices for defects in the GI tract

Gastrointestinal luminal defects, including perforations, leaks and fistulae, pose persistent obstacles in endoscopic therapeutic interventions. A variety of endoscopic approaches have been proposed, with through-the-scope clipping (TTSC), over-the-scope clipping (OTSC) and suturing representing the main techniques of tissue apposition. However, the heterogeneity in defect morphology, the technical particularities of different locations in the gastrointestinal (GI) tract and the impact of various parameters on the final outcome, do not allow distinct conclusions and recommendations on the optimal approaches for defect closure, and, thus, current practice is based on endoscopists experience and local availability of devices. This review aims to collect the existing evidence on tissue apposition devices, in order to outline the role of every device on specific indications.

Closure of gastrointestinal perforations using an endoloop system and a single-channel endoscope: description of a simple, reproducible, and standardized method

BACKGROUND

Several endoscopic treatments for iatrogenic perforations are currently available, with some limitations in terms of size, location, complexity, or cost. Our aims were to introduce a novel technique for closure, using an endoloop and clips, to assess its rate of technical success and post-resection complications.

METHODS

For closure of large perforations (diameter ≥ 10 mm), two similar techniques were implemented, using a single-channel endoscope. An endoloop was deployed through the operating channel or towed by an endoclip alongside the endoscope. Several clips were utilized to fix it on the muscular layer of defect's margins. The defect was closed, by fastening the loop either directly or after being reattached to the mobile hook.

RESULTS

This analysis included eleven patients (72% women, median age 68 years). Eight colorectal, one appendiceal, and two gastric lesions were resected, with a median perforation size of 15 mm. As confirmed by computed tomography, closure of wall defects was achieved successfully in all cases, using a median of 6 clips. Pneumoperitoneum was evacuated in 4 cases. The median hospitalization duration was 4 days, prophylactic antibiotics being prescribed for a median of 7 days. One patient had a small abdominal collection, without requiring drainage, while another presented post-resection bleeding from the mucosal defect.

CONCLUSION

The novel techniques, utilizing a single-channel endoscope, clips, and an endoloop, ensuring an edge-to-edge suture of muscular layer, proved to be safe, reproducible, and easy to implement. They exhibit an excellent technical success rate and a minimal incidence of non-severe complications.

Continuous suture technique increases the complete closure rate of colorectal mucosal defects after endoscopic resection: a single-blind, randomized controlled trial

BACKGROUND

Complete closure of mucosal defects after colorectal endoscopic submucosal dissection (ESD)/piecemeal endoscopic mucosal resection (p-EMR) procedures reduces postoperative adverse events, but the complete closure rate of the traditional method using only hemostatic clips is not satisfactory. Therefore, we invented a continuous suture technique using a barbed suture and clips to increase the complete closure rate of colorectal mucosal defects.

METHODS

Patients with a single large (≥ 2 cm) colorectal lesion were recruited. After completion of the ESD/p-EMR procedures, they were randomly allocated to the treatment group or control group. The mucosal defects of the treatment group were closed using barbed suture and clips, while the control group was closed using only clips.

RESULTS

From January 18, 2022 to April 13, 2022, a total of 62 patients with colorectal lesions were enrolled, with 31 patients in each group. Complete closure was achieved in 29 patients (93.5%) in the treatment group and 18 patients (58.1%) in the control group (P = 0.001). The median closure time was 13 min in the treatment group and 19 min in the control group (P < 0.001). The median closure speed was 6.4 cm2/10 min in the treatment group and 3.5 cm2/10 min in the control group (P = 0.008).

CONCLUSIONS

This study provided a clinically feasible continuous suture technique that was safe and effective for the complete closure of colorectal mucosal defects after endoscopic resection.

Feasibility and efficacy of endoscopic purse-string suture-assisted closure for mucosal defects induced by endoscopic manipulations

BACKGROUND

Large or transmural defects induced by gastrointestinal endoscopic manipulations are difficult to close, although complete closure is recommended for better recovery. Endoscopic purse-string assisted suturing (EPSS) has been used in clinical practice and has proven to be an effective and safe technique for the closure of large mucosal defects. However, details regarding the efficacy of endoscopic pre-purse-string suture (P-EPSS) are unknown, especially that it offers several advantages over conventional EPSS (C-EPSS).

AIM

To elucidate the outcomes of EPSS-assisted closure in different clinical situations, and evaluate the efficacy of P-EPSS.

METHODS

This retrospective observational study included a total of 180 patients who underwent closure assisted by P-EPSS (n = 63) or C-EPSS (n = 117) between July 2014 and June 2020. The P-EPSS and C-EPSS groups were compared and the intergroup differences in aspects such as the lesion size, location, and mor-phology, incidence of complete closure, intraoperative perforation, and delayed adverse events were evaluated. Data on the features and clinical course of cases with adverse events were collected for further analysis.

RESULTS

Patients with lesion size larger than 3 cm, lesions located at the fundus of stomach, or submucosal tumors originating from the deep mucosa were more likely to undergo P-EPSS-assisted closure. The P-EPSS group showed a sign-ificantly higher proportion of intraoperative perforation (56% vs 17%) and a much shorter procedure time (9.06 ± 6.14 min vs 14.84 ± 7.25 min). Among adverse events, the incidence of delayed perforation (5% vs 4%; P = 0.82) and delayed bleeding (3% vs 4%; P = 0.96) did not differ significantly between the groups. Multivariate analysis revealed that lesions with incomplete closure [odds ratio (OR) = 21.33; 95% confidence interval (CI): 5.45-83.45; P < 0.01] or size greater than 3 cm (OR = 3.14; 95%CI: 1.08-9.18; P = 0.039) showed a statistical tendency to result in an increase in delayed adverse events.

CONCLUSION

The present study revealed that EPSS could achieve secure complete closure of mucosal defect. P-EPSS could shorten the procedure and yield complete closure of mucosal defects. Rather than closure-type selection, incomplete closure or lesion size larger than 3 cm were associated with worse outcomes.

Endoscopic full-thickness resection, indication, methods and perspectives

Minimally invasive surgery has emerged as the dominant theme of modern surgery, in which endoscopic surgery plays a key role. The technique of endoscopic surgery has evolved continuously with extensive research, improving the treatment modalities as well as expanding the indications for its use. As an active perforation endoscopic technique, endoscopic full-thickness resection (EFTR) is mainly used in the treatment of submucosal tumors (SMTs) of the gastrointestinal tract. With decades of evolution, EFTR has gradually developed into a mature endoscopic operation. Based on clinical experience and current research, indications, techniques, clinical outcomes and future perspectives for EFTR are discussed in this paper. We performed a bibliometric study on EFTR literature and showed robust data through a brief meta-analysis on the topic.

Minimally invasive management of large duodenal lipoma: endoscopic submucosal dissection

Objective

This study was performed to compare the clinical outcomes of large duodenal lipomas (DLs) of ≥2 cm between endoscopic submucosal dissection (ESD) and endoscopic full-thickness resection (EFTR).

Methods

This retrospective study included patients who underwent endoscopic resection of large DLs from June 2017 to March 2021 at our hospital. Clinicopathologic features, clinical outcomes, and follow-up endoscopy findings were retrospectively reviewed.

Results

Twenty-three patients (12 men) with a mean age of 57.4 years were included. The median tumor size was 28.4 ± 13.3 mm. ESD was performed in 19 patients, and EFTR was performed in 4. Complete resection was achieved in 21 patients. The operative time and postoperative hospital stay were significantly shorter in the ESD than EFTR group. Four patients in the EFTR group developed a fever; no other adverse events occurred. No patients required surgical intervention. During the average follow-up of 21.1 months, no residual tumor, recurrence, or metastasis was observed.

Conclusion

Both ESD and EFTR provide minimally invasive, localized treatment of selected DLs. ESD might have some advantages in resecting large DLs in terms of procedure time and hospitalization.