1
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Siddharthan R, Marcello P. Assessment and Techniques for Endoscopic Closure. Clin Colon Rectal Surg 2024; 37:302-308. [PMID: 39132205 PMCID: PMC11309801 DOI: 10.1055/s-0043-1770944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2024]
Abstract
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.
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Affiliation(s)
| | - Peter Marcello
- Department of Colon and Rectal Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts
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2
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Ulkucu A, Erozkan K, Gorgun E. One step closer to a fully flexible platform: OverStitch and DiLumen C1 systems-A video vignette. Colorectal Dis 2024; 26:1644-1645. [PMID: 38858831 DOI: 10.1111/codi.17061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Accepted: 05/26/2024] [Indexed: 06/12/2024]
Affiliation(s)
- Attila Ulkucu
- Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Kamil Erozkan
- Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Emre Gorgun
- Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio, USA
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3
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Walia A, Trasolini RP, Shahidi N. Double-nylon purse-string suture technique: Another addition to the endoscopist's toolbox for full-thickness defect closure. World J Gastroenterol 2024; 30:3152-3154. [PMID: 39006385 PMCID: PMC11238673 DOI: 10.3748/wjg.v30.i25.3152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 05/23/2024] [Accepted: 06/11/2024] [Indexed: 07/01/2024] Open
Abstract
Iatrogenic perforation is the most feared adverse event in endoscopy. With the expansion of interventional endoscopy in favor of traditional surgery, it is now more crucial than ever to develop effective defect closure techniques. This has culminated in the dissemination of multiple novel closure technologies, including through-the-scope clips, over-the-scope clips, through-the-scope suturing and over-the-scope suturing devices. In this editorial, we comment on the recent publication by Wang and colleagues discussing the performance of the double-nylon purse-string suture technique in the closure of large (> 3 cm) gastric full-thickness defects. This technique offers a promising, practical and cost-effective approach to closure of large full-thickness defects that can be readily implemented across diverse healthcare settings.
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Affiliation(s)
- Angad Walia
- Department of Medicine, University of British Columbia, Vancouver V6Z2K5, BC, Canada
| | | | - Neal Shahidi
- Department of Medicine, University of British Columbia, Vancouver V6Z2K5, BC, Canada
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4
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Papaefthymiou A, Norton B, Telese A, Murray C, Murino A, Johnson G, Tsiopoulos F, Simons-Linares R, Seghal V, Haidry R. Endoscopic suturing and clipping devices for defects in the GI tract. Best Pract Res Clin Gastroenterol 2024; 70:101915. [PMID: 39053973 DOI: 10.1016/j.bpg.2024.101915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Accepted: 05/02/2024] [Indexed: 07/27/2024]
Abstract
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.
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Affiliation(s)
| | - Benjamin Norton
- Division of Gastroenterology, Cleveland Clinic, London, UK; Division of Surgery and Interventional Science, University College London, London, UK
| | - Andrea Telese
- Division of Gastroenterology, Cleveland Clinic, London, UK; Division of Surgery and Interventional Science, University College London, London, UK
| | - Charlie Murray
- Division of Gastroenterology, Cleveland Clinic, London, UK
| | - Alberto Murino
- Division of Gastroenterology, Cleveland Clinic, London, UK
| | - Gavin Johnson
- Division of Gastroenterology, Cleveland Clinic, London, UK
| | - Fotios Tsiopoulos
- Division of Gastroenterology, General Hospital of Larissa, Larissa, Greece
| | - Roberto Simons-Linares
- Gastroenterology and Hepatology Department, Digestive Disease Institute, Cleveland Clinic, Cleveland, OH, 44195, United States
| | - Vinay Seghal
- Endoscopy Department, University College London Hospitals, London, UK
| | - Rehan Haidry
- Division of Gastroenterology, Cleveland Clinic, London, UK.
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5
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Firkins SA, Simons-Linares R. Management of leakage and fistulas after bariatric surgery. Best Pract Res Clin Gastroenterol 2024; 70:101926. [PMID: 39053976 DOI: 10.1016/j.bpg.2024.101926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 06/04/2024] [Indexed: 07/27/2024]
Affiliation(s)
- Stephen A Firkins
- Bariatric and Metabolic Endoscopy, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Roberto Simons-Linares
- Bariatric and Metabolic Endoscopy, Digestive Diseases and Surgery Institute, Cleveland Clinic, Cleveland, OH, USA.
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Xiong K, Xu L. The Model Study of Phase-Transitional Magnetic-Driven Micromotors for Sealing Gastric Perforation via Mg-Based Micropower Traction. NANOMATERIALS (BASEL, SWITZERLAND) 2024; 14:865. [PMID: 38786822 PMCID: PMC11123717 DOI: 10.3390/nano14100865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 05/13/2024] [Accepted: 05/13/2024] [Indexed: 05/25/2024]
Abstract
Gastric perforation refers to the complete rupture of the gastric wall, leading to the extravasation of gastric contents into the thoracic cavity or peritoneum. Without timely intervention, the expulsion of gastric contents may culminate in profound discomfort, exacerbating the inflammatory process and potentially triggering perilous sepsis. In clinical practice, surgical suturing or endoscopic closure procedures are commonly employed. Magnetic-driven microswarms have also been employed for sealing gastrointestinal perforation. However, surgical intervention entails significant risk of bleeding, while endoscopic closure poses risks of inadequate closure and the need for subsequent removal of closure clips. Moreover, the efficacy of microswarms is limited as they merely adhere to the perforated area, and their sealing effect diminishes upon removal of the magnetic field. Herein, we present a Fe&Mg@Lard-Paraffin micromotor (LPM) constructed from a mixture of lard and paraffin coated with magnesium (Mg) microspheres and iron (Fe) nanospheres for sutureless sealing gastric perforations. Under the control of a rotating magnetic field, this micromotor demonstrates precise control over its movement on gastric mucosal folds and accurately targets the gastric perforation area. The phase transition induced by the high-frequency magnetothermal effect causes the micromotor composed of a mixed oil phase of lard and paraffin to change from a solid to a liquid phase. The coated Mg microspheres are subsequently exposed to the acidic gastric acid environment to produce a magnesium protonation reaction, which in turn generates hydrogen (H2) bubble recoil. Through a Mg-based micropower traction, part of the oil phase could be pushed into the gastric perforation, and it would then solidify to seal the gastric perforation area. Experimental results show that this can achieve long-term (>2 h) gastric perforation sealing. This innovative approach holds potential for improving outcomes in gastric perforation management.
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Affiliation(s)
| | - Leilei Xu
- State Key Laboratory of Advanced Technology for Materials Synthesis and Processing, Wuhan University of Technology, Wuhan 430070, China;
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Canakis A, Irani SS. Endoscopic repair of a perforated duodenal ulcer: time to close the gap. VIDEOGIE : AN OFFICIAL VIDEO JOURNAL OF THE AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY 2024; 9:247-250. [PMID: 38766398 PMCID: PMC11099307 DOI: 10.1016/j.vgie.2024.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
Video 1Management of an acute perforated duodenal ulcer.
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Affiliation(s)
- Andrew Canakis
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Shayan S Irani
- Division of Gastroenterology and Hepatology, Virginia Mason Medical Center, Seattle, Washington
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Marin FS, Assaf A, Doumbe-Mandengue P, Abou Ali E, Belle A, Coriat R, Chaussade S. Closure of gastrointestinal perforations using an endoloop system and a single-channel endoscope: description of a simple, reproducible, and standardized method. Surg Endosc 2024; 38:1600-1607. [PMID: 38242987 DOI: 10.1007/s00464-023-10654-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 12/17/2023] [Indexed: 01/21/2024]
Abstract
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.
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Affiliation(s)
- Flavius-Stefan Marin
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France.
- University of Medicine and Pharmacy "Carol Davila", Bucharest, Romania.
| | - Antoine Assaf
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
- Faculty of Medicine, The University of Paris Cité, Paris, France
| | - Paul Doumbe-Mandengue
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Einas Abou Ali
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Arthur Belle
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
| | - Romain Coriat
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
- Faculty of Medicine, The University of Paris Cité, Paris, France
| | - Stanislas Chaussade
- Department of Gastroenterology and Digestive Oncology, Cochin Hospital, Assistance Publique - Hôpitaux de Paris, Paris, France
- Faculty of Medicine, The University of Paris Cité, Paris, France
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Agnihotri A, Mitsuhashi S, Holmes I, Kamal F, Chiang A, Loren DE, Kowalski TE, Schlachterman A, Kumar AR. Randomized trial of gastric and colorectal endoscopic submucosal dissection defect closure comparing a novel through-the-scope suturing system with an over-the-scope suturing system (with video). Gastrointest Endosc 2024; 99:237-244.e1. [PMID: 37536633 DOI: 10.1016/j.gie.2023.07.046] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 05/16/2023] [Accepted: 07/23/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND AND AIMS Mucosal closure adds time but reduces adverse events associated with endoscopic submucosal dissection (ESD). We aimed to assess the closure time (CT), technical success, and cost-effectiveness between a novel through-the-scope helix tack suture system (TTSS) and the over-the-scope suturing system (OTSS). METHODS In this single-center, prospective, randomized trial, all patients undergoing ESD with anticipated closure were randomized 1:1 to TTSS (study group) or OTSS (control group). Primary outcomes were CT and overall CT (OCT; CT + setup time). Secondary outcomes were rates of technical success, adverse events, and cost-effectiveness. RESULTS Forty patients were randomized to OTSS (n = 20) or TTSS (n = 20). OTSS and TTSS groups were similar with respect to age, gender, proportion of colorectal polyps, proximal colon polyps, and mean size of the resected specimen (40.9 mm vs 40.4 mm). The mean CT was 18.4 minutes for OTSS and 23.3 minutes for TTSS (P = .36). The mean OCT was 32 minutes for OTSS and 39.5 minutes for TTSS (P = .36). Closure with a primary device was successful in 17 cases (85%) with OTSS and 18 cases (90%) with TTSS (P = .63). No closure-related intraprocedural adverse events or delayed perforations were noted. Mean cost of closure was significantly lower in the TTSS group for lesions <35 mm (P = .008). CONCLUSIONS TTSS was not found to be superior to OTSS with respect to CT and technical and clinical success for closure of gastric and colorectal ESD defects. TTSS is more cost-effective for closure of lesions <35 mm. (Clinical trial registration number: NCT04925271.).
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Affiliation(s)
- Abhishek Agnihotri
- Division of Gastroenterology, Bayhealth Medical Center, Dover, Delaware, USA
| | - Shuji Mitsuhashi
- Division of Gastroenterology & Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Ian Holmes
- Division of Gastroenterology, The Oregon Clinic, Portland, Oregon, USA
| | - Faisal Kamal
- Division of Gastroenterology & Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Austin Chiang
- Division of Gastroenterology & Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - David E Loren
- Division of Gastroenterology & Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Thomas E Kowalski
- Division of Gastroenterology & Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Alexander Schlachterman
- Division of Gastroenterology & Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Anand R Kumar
- Division of Gastroenterology & Hepatology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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10
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Canakis A, Dawod SM, Dawod E, Simons M, Di Cocco B, Westerveld DR, Trasolini RP, Berzin TM, Marshall CA, Abdelfattah AM, Marya NB, Smallfield GB, Kaspar M, Campos GM, Skef W, Kedia P, Smith TA, Aihara H, Moyer MT, Sampath K, Mahadev S, Carr-Locke DL, Sharaiha RZ. Efficacy, Feasibility, and Safety of the X-Tack Endoscopic HeliX Tacking System: A Multicenter Experience. J Clin Gastroenterol 2024:00004836-990000000-00261. [PMID: 38277501 DOI: 10.1097/mcg.0000000000001977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Accepted: 01/04/2024] [Indexed: 01/28/2024]
Abstract
BACKGROUND AND AIMS The application of endoscopic suturing has revolutionized defect closures. Conventional over-the-scope suturing necessitates removal of the scope, placement of the device, and reinsertion. A single channel, single sequence, through-the-scope suturing device has been developed to improve this process. This study aims to describe the efficacy, feasibility, and safety of a through-the-scope suturing device for gastrointestinal defect closure. METHODS This was a retrospective multicenter study involving 9 centers of consecutive adult patients who underwent suturing using the X-Tack Endoscopic HeliX Tacking System (Apollo Endosurgery). The primary outcomes were technical success and long-term clinical success. Secondary outcomes included adverse events, recurrence, and reintervention rates. RESULTS In all, 56 patients (mean age 53.8, 33 women) were included. Suturing indications included fistula repair (n=22), leak repair (n=7), polypectomy defect closure (n=12), peroral endoscopic myotomy (POEM) site closure (n=7), perforation repair (n=6), and ulcers (n=2). Patients were followed at a mean duration of 74 days. Overall technical and long-term clinical success rates were 92.9% and 75%, respectively. Both technical and clinical success rates were 100% for polypectomies, POEM-site closures, and ulcers. Success rates were lower for the repair of fistulas (95.5% technical, 54.5% clinical), leaks (57.1%, 28.6%), and perforations (100%, 66.7%). No immediate adverse events were noted. CONCLUSION This novel, through-the-scope endoscopic suturing system, is a safe and feasible method to repair defects that are ≤3 cm. The efficacy of this device may be better suited for superficial defects as opposed to full-thickness defects. Larger defects will need more sutures and probably a double closure technique to provide a reinforcement layer.
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Affiliation(s)
- Andrew Canakis
- Department of Gastroenterology, University of Maryland Medical Center, Baltimore, MD
| | - Sanad Maher Dawod
- Department of Gastroenterology, Weill Cornell Medical Center, New York, NY
| | - Enad Dawod
- Department of Gastroenterology, Weill Cornell Medical Center, New York, NY
| | - Malorie Simons
- Department of Gastroenterology, Weill Cornell Medical Center, New York, NY
| | - Bianca Di Cocco
- Department of Gastroenterology, Weill Cornell Medical Center, New York, NY
| | | | | | - Tyler M Berzin
- Department of Gastroenterology, Beth Israel Deaconess Medical Center, Boston
| | | | | | - Neil B Marya
- Department of Gastroenterology, UMass Memorial Medical Center, Worcester, MA
| | - George B Smallfield
- Department of Gastroenterology, Virginia Commonwealth University, Richmond, VA
| | - Matthew Kaspar
- Department of Gastroenterology, Virginia Commonwealth University, Richmond, VA
| | - Guilherme M Campos
- Department of Gastroenterology, Virginia Commonwealth University, Richmond, VA
| | - Wasseem Skef
- Department of Gastroenterology, Loma Linda University Medical Center, Loma Linda, CA
| | - Prashant Kedia
- Department of Gastroenterology, Methodist Dallas Medical Center, Dallas, TX
| | - Terrence A Smith
- Department of Gastroenterology, Vanderbilt University Medical Center, Nashville, TN
| | - Hiroyuki Aihara
- Department of Gastroenterology, Brigham and Women's Hospital
| | - Matthew T Moyer
- Department of Gastroenterology, Penn State Health Milton S Hershey Medical Center. Hershey, PA
| | - Kartik Sampath
- Department of Gastroenterology, Weill Cornell Medical Center, New York, NY
| | - Srihari Mahadev
- Department of Gastroenterology, Weill Cornell Medical Center, New York, NY
| | - David L Carr-Locke
- Department of Gastroenterology, Weill Cornell Medical Center, New York, NY
| | - Reem Z Sharaiha
- Department of Gastroenterology, Weill Cornell Medical Center, New York, NY
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11
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Keihanian T, Zabad N, Khalaf M, Abdel-Jaber W, Kim YI, Jawaid SA, Abidi WM, Marginean EC, Othman MO. Safety and efficacy of a novel suturing device for closure of large defects after endoscopic submucosal dissection (with video). Gastrointest Endosc 2023; 98:381-391. [PMID: 37061137 DOI: 10.1016/j.gie.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Revised: 01/14/2023] [Accepted: 04/08/2023] [Indexed: 04/17/2023]
Abstract
BACKGROUND AND AIMS Endoscopic suturing enables full closure of large defects after endoscopic submucosal dissection (ESD). However, its use is limited by the need for a double-channel endoscope. A novel closure system, the OverStitch Sx (Apollo Endosurgery, Austin, Tex, USA), compatible with any single-channel endoscope, was introduced to address these shortcomings. The aim of this study was to assess the safety and feasibility of OverStitch Sx for the closure of large defects after ESD. METHODS This is a prospective single-center feasibility study of patients who underwent closure of large defects after ESD using the OverStitch Sx system. Main outcomes of the study are technical and clinical success, same-day discharge rate, and adverse event rate. RESULTS Thirty-three patients were enrolled. The 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 event rate was 35.7%, including delayed bleeding in 1 patient after rectal ESD that was managed conservatively, self-resolving rectal pain in 7 patients, rectal stricture requiring dilation in 1 patient, and temporary dysphagia in 1 patient. No immediate or delayed perforation was reported. CONCLUSIONS OverStitch Sx enabled safe and effective closure of large defects after ESD. Future trials are needed to determine its superiority over OverStitch for the closure of defects in challenging locations. (Clinical trial registration number: NCT04361227.).
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Affiliation(s)
| | - Noor Zabad
- Department of Medicine, Division of Gastroenterology
| | - Mai Khalaf
- Department of Medicine, Division of Gastroenterology
| | | | - Young-Il Kim
- Department of Medicine, Division of Gastroenterology
| | | | - Wasif M Abidi
- Department of Medicine, Division of Gastroenterology
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12
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Pattarajierapan S, Takamaru H, Khomvilai S. Difficult colorectal polypectomy: Technical tips and recent advances. World J Gastroenterol 2023; 29:2600-2615. [PMID: 37213398 PMCID: PMC10198056 DOI: 10.3748/wjg.v29.i17.2600] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 02/24/2023] [Accepted: 04/12/2023] [Indexed: 05/23/2023] Open
Abstract
Colonoscopy has been shown to be an effective modality to prevent colorectal cancer (CRC) development. CRC reduction is achieved by detecting and removing adenomas, which are precursors of CRC. Most colorectal polyps are small and do not pose a significant challenge for trained and skilled endoscopists. However, up to 15% of polyps are considered “difficult”, potentially causing life-threatening complications. A difficult polyp is defined as any polyp that is challenging for the endoscopist to remove owing to its size, shape, or location. Advanced polypectomy techniques and skills are required to resect difficult colorectal polyps. There were various polypectomy techniques for difficult polyps such as endoscopic mucosal resection (EMR), underwater EMR, Tip-in EMR, endoscopic submucosal dissection (ESD), or endoscopic full-thickness resection. The selection of the appropriate modality depends on the morphology and endoscopic diagnosis. Several technologies have been developed to aid endoscopists in performing safe and effective polypectomies, especially complex procedures such as ESD. These advances include video endoscopy system, equipment assisting in advanced polypectomy, and closure devices/techniques for complication management. Endoscopists should know how to use these devices and their availability in practice to enhance polypectomy performance. This review describes several useful strategies and tips for managing difficult colorectal polyps. We also propose the stepwise approach for difficult colorectal polyps.
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Affiliation(s)
- Sukit Pattarajierapan
- Surgical Endoscopy Colorectal Division, Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
| | - Hiroyuki Takamaru
- Endoscopy Division, National Cancer Center Hospital, Tokyo 104-0045, Japan
| | - Supakij Khomvilai
- Surgical Endoscopy Colorectal Division, Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok 10330, Thailand
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13
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Othman MO, Diehl DL, Khara HS, Jawaid S, Yang D, Draganov PV. Multicenter prospective evaluation of an overtube endoluminal interventional platform for colorectal polypectomy. Endosc Int Open 2023; 11:E519-E526. [PMID: 37206694 PMCID: PMC10191729 DOI: 10.1055/a-2057-4286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 02/10/2023] [Indexed: 05/21/2023] Open
Abstract
Background and study aims Endoscopic removal of complex colorectal polyps (≥ 2 cm) can be technically challenging. A dual balloon endoluminal overtube platform (DBEP) was developed to facilitate colonoscopic polypectomy. The study purpose was to evaluate clinical outcomes with the DBEP for complex polypectomy. Patients and methods This was an observational, prospective, multicenter Institutional Review Board-approved study. Between January 2018 and December 2020, safety and performance data were collected intra-procedurally and at 1 month post-procedure in patients undergoing intervention with the DBEP at three US centers. The primary endpoint was device safety and technical success of the procedure. Secondary endpoints included navigation time, total procedure time, and user feedback assessment post-procedure. Results A total of 162 patients underwent colonoscopy with the DBEP. Of these, 144 (89 %) underwent 156 interventions successfully with DBEP (44.5 % endoscopic mucosal resection, 53.2 % hybrid endoscopic submucosal dissection (ESD)/ESD, 1.3 % other). In 13 patients (8 %), device challenges contributed to unsuccessful intervention. One mild device-related adverse event (AE) occurred. Procedural AE rate was 8.3 %. Median lesion size was 2.6 cm [range 0.5-12]. The investigators felt that navigating the device was easy/somewhat easy in 78.5 % of successful cases. Median total procedure time was 69 minutes [range, 19-213], median navigation time to lesion was 8 minutes [range, 1-80], And median polypectomy time was 33.5 minutes [range, 2-143]. Conclusions Endoscopic colon polyp resection with the DBEP was safe with a high technical success rate. The DBEP has the potential to provide enhanced scope stability and visualization, traction, and a conduit for scope exchange. Further prospective randomized studies are warranted.
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Affiliation(s)
- Mohamed O. Othman
- Division of Gastroenterology Baylor St. Luke’s Medical Center Houston, Texas, United States
| | - David L. Diehl
- Division of Gastroenterology Geisinger Health System Danville, Pennsylvania, United States
| | - Harshit S. Khara
- Division of Gastroenterology Geisinger Health System Danville, Pennsylvania, United States
| | - Salman Jawaid
- Division of Gastroenterology Baylor St. Luke’s Medical Center Houston, Texas, United States
| | - Dennis Yang
- Division of Gastroenterology University Florida Gainesville, Florida, United States
| | - Peter V. Draganov
- Division of Gastroenterology University Florida Gainesville, Florida, United States
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Steinbrück I, Pohl J, Grothaus J, von Hahn T, Rempel V, Faiss S, Dumoulin FL, Schmidt A, Hagenmüller F, Allgaier HP. Characteristics and endoscopic treatment of interventional and non-interventional iatrogenic colorectal perforations in centers with high endoscopic expertise: a retrospective multicenter study. Surg Endosc 2023:10.1007/s00464-023-09920-z. [PMID: 36759355 DOI: 10.1007/s00464-023-09920-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 01/28/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND Iatrogenic colorectal perforation is a rare event with a relevant mortality and the need for surgical therapy in around ¾ of cases. METHODS In this retrospective multicentric cohort study iatrogenic colorectal perforations from 2004 to 2021 were analyzed. Primary outcome parameters were incidence and clinical success of 1st line endoscopic treatment. Comparative analysis of interventional and non-interventional perforations was performed and predictors for clinical success of endoscopic therapy were identified. RESULTS From 103,570 colonoscopies 213 (0.2%) iatrogenic perforations were identified. 68.4% were interventional (80 during polypectomy/EMR, 54 during ESD and 11 for other reasons) and 31.6% non-interventional perforations (39 by the tip, 19 by the shaft, 7 by inversion, two by biopsy and one by distension). Incidence of 1st line endoscopic therapy was 61.0% and clinical success 81.5%. Other non-surgical therapies were conducted in 8.9% with clinical success in 94.7% of cases. In interventional perforations both incidence and clinical success of 1st line endoscopic therapy were significantly higher compared to non-interventional perforations [71.7% vs. 38.2% (p < 0.01) resp. 86.5% vs. 61.5% (p < 0.01)]. Mortality was 2.3% and significantly lower in the group of interventional perforations (0.7% vs. 5.9%, p = 0.037). Multivariable analysis revealed perforation size < 5 mm as only independent predictor for clinical success of 1st line endoscopic treatment [OR 14.85 (1.57-140.69), p = 0.019]. CONCLUSIONS Endoscopic therapy is treatment of choice in the majority of iatrogenic colorectal perforations. In case of interventional perforations it is highly effective but only a minority of non-interventional perforations are good candidates for endoscopic treatment.
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Affiliation(s)
- Ingo Steinbrück
- Department of Medicine and Gastroenterology, Evangelisches Diakoniekrankenhaus Freiburg, Academic Teaching Hospital, University of Freiburg, Wirthstraße 11, 79110, Freiburg, Germany.
| | - Jürgen Pohl
- Department of Gastroenterology, Asklepios Klinik Altona, Academic Teaching Hospital University of Hamburg, Hamburg, Germany
| | - Johannes Grothaus
- Department of Gastroenterology, Asklepios Klinik Altona, Academic Teaching Hospital University of Hamburg, Hamburg, Germany
| | - Thomas von Hahn
- Department of Gastroenterology, Hepatology and Endoscopy, Asklepios Klinik Barmbek, Academic Teaching Hospital University of Hamburg, Hamburg, Germany
| | - Viktor Rempel
- Department of Gastroenterology, St. Anna Hospital Herne, Academic Teaching Hospital Ruhr University Bochum, Herne, Germany
| | - Siegbert Faiss
- Department of Gastroenterology, Sana Klinikum Lichtenberg, Academic Teaching Hospital, Universtiy of Berlin, Berlin, Germany
| | - Franz Ludwig Dumoulin
- Department of Medicine and Gastroenterology, Gemeinschaftskrankenhaus Bonn, Academic Teaching Hospital, University of Bonn, Bonn, Germany
| | - Arthur Schmidt
- Department of Gastroenterology and Hepatology, University of Freiburg, Freiburg, Germany
| | - Friedrich Hagenmüller
- Department of Gastroenterology, Asklepios Klinik Altona, Academic Teaching Hospital University of Hamburg, Hamburg, Germany
| | - Hans-Peter Allgaier
- Department of Medicine and Gastroenterology, Evangelisches Diakoniekrankenhaus Freiburg, Academic Teaching Hospital, University of Freiburg, Wirthstraße 11, 79110, Freiburg, Germany
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15
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Abdallah M, Suryawanshi G, McDonald N, Chandan S, Umar S, Azeem N, Bilal M. Endoscopic full-thickness resection for upper gastrointestinal tract lesions: a systematic review and meta-analysis. Surg Endosc 2022; 37:3293-3305. [PMID: 36517704 DOI: 10.1007/s00464-022-09801-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 11/27/2022] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Endoscopic full-thickness resection (EFTR) is used to resect difficult superficial mucosal lesions and sub-epithelial lesions (SELs). We conducted a systematic review and meta-analysis to evaluate the efficacy and safety of EFTR for upper gastrointestinal tract (GIT) lesions. METHODS We conducted a comprehensive literature search of MEDLINE, EMBASE, Cochrane, ClinicalTrials.gov, and Scopus databases for studies published in the English language that addressed outcomes of EFTR for upper GIT lesions through November 2021. The weighted pooled rates with the 95% confidence interval (CI) were calculated. Cochran Q test and I statistics were used to calculate heterogeneity. RESULTS We identify 740 articles on the initial search and six studies met the inclusion criteria. 140 patients (45.7% females) with 142 lesions were analyzed. Four studies used the full-thickness resection device (FTRD®). EFTR was performed for 26 adenomas, 97 SELs, six adenocarcinomas, and ten full-thickness biopsies. The overall technical success rate was 86.9% (CI 79.8-94%, I 2 = 38.9%), R0 resection was 80% (CI 67.6-92.3%, I 2 = 75.6%), and the overall adverse events rate was 18.6% (9.8-27.2%, I 2 = 49.4%). Major adverse events included six episodes of major bleeding, three micro-perforations, one large duodenal perforation, and one case of mucosal damage from FTRD®. At 3-6 months follow-up, there were only two cases of recurrence (R0 was not achieved in both). CONCLUSION EFTR has a high technical and clinical success rate in managing upper GIT lesions with an acceptable safety profile. Large prospective studies comparing EFTR with conventional endoscopic resection techniques are needed.
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Affiliation(s)
- Mohamed Abdallah
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, 406 Harvard St SE, MMC36, Minneapolis, MN, 55455, USA.
| | - Gaurav Suryawanshi
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, 406 Harvard St SE, MMC36, Minneapolis, MN, 55455, USA
| | - Nicholas McDonald
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, 406 Harvard St SE, MMC36, Minneapolis, MN, 55455, USA
| | - Saurabh Chandan
- Division of Gastroenterology and Hepatology and Nutrition, Creighton University, Omaha, NE, USA
| | - Shifa Umar
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - Nabeel Azeem
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, 406 Harvard St SE, MMC36, Minneapolis, MN, 55455, USA
| | - Mohammad Bilal
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, 406 Harvard St SE, MMC36, Minneapolis, MN, 55455, USA
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16
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Hustak R, Vackova Z, Krajciova J, Spicak J, Kieslichova E, Mares J, Martinek J. Endoscopic clips versus overstitch suturing system device for mucosotomy closure after peroral endoscopic pyloromyotomy (G-POEM): a prospective single-center study. Surg Endosc 2022; 36:9254-9261. [PMID: 35851820 DOI: 10.1007/s00464-022-09417-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Accepted: 06/24/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND AIMS G-POEM is an emerging method for treatment of severe gastroparesis. Safe mucosal closure is necessary to avoid adverse events. The aim of this study was to compare the efficacy of two closure methods: clips and endoscopic suturing (ES) after G-POEM. METHODS We performed a single center, prospective study. The closure method was assigned at the discretion of an endoscopist prior to the procedure. The main outcome was the proportion of subjects with successful closure. Unsuccessful closure was defined as a need for a rescue method, or a need for an additional intervention or incomplete closure-related adverse events. Secondary outcomes were the easiness of closure (VAS score 1 = very difficult, 10 = easy), closure time, and cost. RESULTS A total of 40 patients [21 female; mean age, range 47.5; (20-74)] were included; 20 received ES and 20 clips [mean number of clips 6; range (4-19)]. All 20 patients with ES (100%, 95% CI 84-100%) and 18 patients with clips (89%, 95% CI 70-97%) had successful closure (p = 0.49). One patient needed a rescue method (KING closure) and the other patient an additional clipping on POD1. Closure with clips was quicker [mean time 9.8 (range 4-20) min vs. 14.1 (5-21) min; p = 0.007] and cheaper [mean cost 807 USD (± 402) vs. 2353 USD (± 145); p < 0.001]. Endoscopist assessed the easiness of ES and clips as comparable [mean VAS, range 7.5 (3-10) (ES) vs. 6.9 (3-10) (clips); p = 0.3]. CONCLUSIONS Both ES and clips are effective methods for mucosal closure in patients undergoing G-POEM. However, centres using clips should have a rescue closure method available as clips may fail in some patients. Closure with ES is more costly than with clips.
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Affiliation(s)
- R Hustak
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
- Institute of Physiology, Charles University in Prague, Prague, Czech Republic
- Department of Internal Medicine, University Hospital Trnava, Trnava, Slovakia
| | - Z Vackova
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
- Institute of Physiology, Charles University in Prague, Prague, Czech Republic
| | - J Krajciova
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
- Institute of Physiology, Charles University in Prague, Prague, Czech Republic
| | - J Spicak
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - E Kieslichova
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - J Mares
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Jan Martinek
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic.
- Institute of Physiology, Charles University in Prague, Prague, Czech Republic.
- Faculty of Medicine, Ostrava University, Ostrava, Czech Republic.
- Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine, Videnska 1921, 140 21, Prague 4, Czech Republic.
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17
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Ali O, Canakis A, Huang Y, Patel H, Alizadeh M, Kim RE. Closure of Mucosal Defects Using Endoscopic Suturing Following Endoscopic Submucosal Dissection: A Single-Center Experience. TECHNIQUES AND INNOVATIONS IN GASTROINTESTINAL ENDOSCOPY 2022; 25:46-51. [PMID: 37799128 PMCID: PMC10552729 DOI: 10.1016/j.tige.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Abstract
Background and Aims Endoscopic submucosal dissection (ESD) is a therapeutic technique for en-bloc resection of both large (>20 mm) and smaller, complex gastrointestinal neoplasms. ESD has a higher success rate of en-bloc resection and a lower rate of local recurrence compared to endoscopic mucosal resection (EMR). Removal of lesions via ESD can leave large mucosal defects, raising unique challenges leading to adverse events. We aimed to determine clinical outcomes including delayed bleeding, perforation and hospitalization in patients undergoing endoscopic suturing following ESD. Methods Single-center retrospective study of a prospectively collected database of consecutive adult patients who underwent ESD with mucosal defect closure using endoscopic suturing. Primary outcomes were adverse events, specifically, delayed bleeding or perforation. Secondary outcomes included need for hospitalization and suturing complications. Results 55 patients (mean age: 67 years) were included with a mean lesion size of 27.4 mm ± 15. Defect closure occurred in the esophagus (6), gastroesophageal junction (2), stomach (30), cecum (2), sigmoid colon (2) and rectum (13). A mean of 1.8 ± 1.0 sutures were required for defect closure. Hospital admission rates were 14% (8/55) with an average length of stay 2 days (range: 1-3 days). Intra-procedure perforation occurred in two patients and both were successfully treated with endoscopic suturing. There was one case of delayed bleeding and no cases of delayed perforation or suturing complications. Conclusion The use of endoscopic suturing following ESD is a safe and clinically reliable method to close mucosal defects. This approach is associated with minimal adverse events and need for hospitalization. Larger studies are needed to further validate these findings.
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Affiliation(s)
- Osman Ali
- Division of Gastroenterology & Hepatology, University of Maryland School of Medicine, Baltimore, MD
| | - Andrew Canakis
- Division of Gastroenterology & Hepatology, University of Maryland School of Medicine, Baltimore, MD
| | - Yuting Huang
- Department of Medicine, University of Maryland Medical Center Midtown Campus, Baltimore, MD
| | - Harsh Patel
- Department of Medicine, University of Maryland Medical Center Midtown Campus, Baltimore, MD
| | - Madeline Alizadeh
- Division of Gastroenterology & Hepatology, University of Maryland School of Medicine, Baltimore, MD
| | - Raymond E. Kim
- Division of Gastroenterology & Hepatology, University of Maryland School of Medicine, Baltimore, MD
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18
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Keihanian T, Othman MO, Jawaid SA. Endoscopic tacking system as a novel tissue approximation measure for very large EMR defects. VideoGIE 2022; 7:419-422. [PMID: 36407047 PMCID: PMC9669601 DOI: 10.1016/j.vgie.2022.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Backgrounds and Aims Defect closure post-EMR and endoscopic submucosal dissection (ESD) is recommended to decrease the risk of delayed bleeding and perforation. Current methods of tissue approximation and closure of mucosal defects have their limitations, including restricted maneuverability, need for scope withdrawal, or difficulty in apposing larger defects. Through-the-scope HeliX tacking system (Apollo Endosurgery, Austin, Tex, USA) is a novel tissue apposition device designed to mimic suture closure without the need to withdraw the endoscope or insert bulky devices on the tip of the endoscope. Previous reports demonstrate its effectiveness for closure of standard postresection defects, fistulae, and peroral endoscopic myotomy mucosectomy sites. However, reports on its feasibility and technique for very large defects are scarce. Methods In this case series, we demonstrate a tissue approximation technique using a novel through-the-scope HeliX tacking system for a 10-cm ascending colon and a 5-cm gastric antrum postresection defects. A zig-zag running pattern and figure 8 suturing pattern were used for the colonic and gastric defect approximation, respectively. Results Tissue approximation was easily and successfully achieved in both cases. Four and 2 sets of tacks were used in the colonic and gastric defect, respectively. Closure of these defects otherwise would have required a substantial number of clips, withdrawal/exchange of the endoscope to mount the suturing device, or difficulty in maneuvering the closure devices. There was no immediate or delayed adverse event postprocedure. Conclusions Through-the-scope suturing using the HeliX tacking system is a unique tool that integrates the capabilities of current tissue apposition devices post EMR and ESD. Through-the-scope suturing is an ideal option especially for tissue approximation of large resection beds within the right side of the colon and areas with limited space for maneuverability.
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Affiliation(s)
- Tara Keihanian
- Department of Medicine, Division of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas
| | - Mohamed O Othman
- Department of Medicine, Division of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas
| | - Salmaan A Jawaid
- Department of Medicine, Division of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas
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19
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Cheng SL, Xie L, Wu HW, Zhang XF, Lou LL, Shen HZ. Metal stent combined with ileus drainage tube for the treatment of delayed rectal perforation: A case report. World J Clin Cases 2022; 10:8406-8416. [PMID: 36159539 PMCID: PMC9403701 DOI: 10.12998/wjcc.v10.i23.8406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 05/18/2022] [Accepted: 07/06/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute iatrogenic colorectal perforation (AICP) is a serious adverse event, and immediate AICP usually requires early endoscopic closure. Immediate surgical repair is required if the perforation is large, the endoscopic closure fails, or the patient's clinical condition deteriorates. In cases of delayed AICP (> 4 h), surgical repair or enterostomy is usually performed, but delayed rectal perforation is rare.
CASE SUMMARY A 53-year-old male patient underwent endoscopic submucosal dissection (ESD) at a local hospital for the treatment of a laterally spreading tumor of the rectum, and the wound was closed by an endoscopist using a purse-string suture. Unfortunately, the patient then presented with delayed rectal perforation (6 h after ESD). The surgeons at the local hospital attempted to treat the perforation and wound surface using transrectal endoscopic microsurgery (TEM); however, the perforation worsened and became enlarged, multiple injuries to the mucosa around the perforation and partial tearing of the rectal mucosa occurred, and the internal anal sphincter was damaged. As a result, the perforation became more complicated. Due to the increased bleeding, surgical treatment with suturing could not be performed using TEM. Therefore, the patient was sent to our medical center for follow-up treatment. After a multidisciplinary discussion, we believed that the patient should undergo an enterostomy. However, the patient strongly refused this treatment plan. Because the position of the rectal perforation was relatively low and the intestine had been adequately prepared, we attempted to treat the complicated delayed rectal perforation using a self-expanding covered mental stent (SECMS) in combination with a transanal ileus drainage tube (TIDT).
CONCLUSION For patients with complicated delayed perforation in the lower rectum and adequate intestinal preparation, a SECMS combined with a TIDT can be used and may result in very good outcomes.
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Affiliation(s)
- Si-Le Cheng
- Department of Gastroenterology, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou 310000, Zhejiang Province, China
- Department of Gastroenterology, Zhejiang Chinese Medical University, Hangzhou 310000, Zhejiang Province, China
| | - Lu Xie
- Department of Gastroenterology, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou 310000, Zhejiang Province, China
| | - Hao-Wei Wu
- Department of Gastroenterology, Zhejiang Chinese Medical University, Hangzhou 310000, Zhejiang Province, China
| | - Xiao-Feng Zhang
- Department of Gastroenterology, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou 310000, Zhejiang Province, China
| | - Li-Lan Lou
- Department of Gastroenterology, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou 310000, Zhejiang Province, China
- Department of Gastroenterology, Zhejiang Chinese Medical University, Hangzhou 310000, Zhejiang Province, China
| | - Hong-Zhang Shen
- Department of Gastroenterology, The Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou 310000, Zhejiang Province, China
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20
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Wu ZW, Ding CH, Song YD, Cui ZC, Bi XQ, Cheng B. Colon Sparing Endoscopic Full-Thickness Resection for Advanced Colorectal Lesions: Is It Time for Global Adoption? Front Oncol 2022; 12:967100. [PMID: 35912240 PMCID: PMC9327091 DOI: 10.3389/fonc.2022.967100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 06/20/2022] [Indexed: 11/13/2022] Open
Abstract
The majority of colon lesions are <10 mm in size and are easily resected by endoscopists with appropriate basic training. Lesions ≥10 mm in size are difficult to remove technically and are associated with higher rates of incomplete resection. Currently, the main endoscopic approaches include endoscopic mucosal resection (EMR) for lesions without submucosal invasion, and endoscopic submucosal dissection (ESD) for relatively larger lesions involving the superficial submucosal layer. Both of these approaches have limitations, EMR cannot reliably ensure complete resection for larger tumors and recurrence is a key limitation. ESD reliably provides complete resection and an accurate pathological diagnosis but is associated with risk such as perforation or bleeding. In addition, both EMR and ESD may be ineffective in treating subepithelial lesions that extend beyond the submucosa. Endoscopic full-thickness resection (EFTR) is an emerging innovative endoscopic therapy which was developed to overcome the limitations of EMR and ESD. Advantages include enabling a transmural resection, complete resection of complex colorectal lesions involving the mucosa to the muscularis propria. Recent studies comparing EFTR with current resection techniques and radical surgery for relatively complicated and larger lesion have provided promising results. If the current trajectory of research and development is maintained, EFTR will likely to become a strong contender as an alternative standard of care for advanced colonic lesions. In the current study we aimed to address this need, and highlighted the areas of future research, while stressing the need for multinational collaboration provide the steppingstone(s) needed to bring EFTR to the mainstream.
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Affiliation(s)
- Zhong-Wei Wu
- Department of Gastrointestinal Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Chao-Hui Ding
- Department of Emergency Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yao-Dong Song
- Department of Emergency Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Zong-Chao Cui
- Department of Emergency Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Xiu-Qian Bi
- Department of Emergency Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Bo Cheng
- Department of Emergency Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
- *Correspondence: Bo Cheng,
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21
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Jiehua Z, Kashif A, YaoSheng C, YunYun S, Lanyu L. Analysis of the Characteristics of Colonoscopy Perforation and Risk Factors for Failure of Endoscopic Treatment. Cureus 2022; 14:e25677. [PMID: 35812566 PMCID: PMC9259074 DOI: 10.7759/cureus.25677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2022] [Indexed: 12/24/2022] Open
Abstract
Background: Many studies have been done regarding perforation after colonoscopy, but few studies analyzed the risk factors of endoscopic treatment failure after colonoscopy perforation. This study aimed to analyze the clinical characteristics and treatment plan of those patients with perforation after colonoscopy diagnosis and the treatment and risk factors of failure to endoscopic treatment. Method: This was a retrospective observational study of patients who underwent colonoscopy examination and treatment at the Affiliated Hospital of Yangzhou University, from 04/2009 to 03/2020. The patients were grouped as perforation, treatment success, or failure (required laparoscopy or laparotomy). Results: From April 2009 to March 2020, 43,470 patients were examined and treated with colonoscopy. There were 35 cases of intestinal perforation, for an incidence of 0.081%. Four patients had immediate surgical intervention (two patients with laparoscopic surgery and two with laparotomy surgery). Thirty-one (88.57%) patients underwent endoscopic treatment. Endoscopic treatment was successful in 20 patients and failed in 11. Compared with the failure group, the perforation size in the success group was smaller (7.60±4.85 vs. 14.4±7.03 mm, P=0.004), hospital stay was shorter (26.6±13.1 vs. 14.2±3.0, P=0.011), and hospitalization costs were lower (30,208±9506 vs. 23,053±6227 RMB, P=0.002). Multivariable logistic stepwise analysis showed that the absence of abdominal pain after therapeutic colonoscopy was independently associated with the success of endoscopic treatment. Conclusions: Endoscopic treatment is logically the preferred modality for perforation management, leading to good recovery, shorter hospital stay, and lower costs of treatment. Postoperative abdominal pain is significantly related to the failure of endoscopic treatment.
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22
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Hayat M, Azeem N, Bilal M. Colon Polypectomy with Endoscopic Submucosal Dissection and Endoscopic Full-Thickness Resection. Gastrointest Endosc Clin N Am 2022; 32:277-298. [PMID: 35361336 DOI: 10.1016/j.giec.2021.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Endoscopic resection has become the gold standard for the management of most of the large colorectal polyps. Various endoscopic resection techniques include endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and endoscopic full-thickness resection (EFTR). ESD is a minimally invasive method for the resection of advanced lesions in the gastrointestinal (GI) tract to achieve en-bloc resection. While, EFTR is more commonly used in lesions with suspected deeper submucosal invasion, lesions originating from muscularis propria, or those with advanced fibrosis. This article reviews the indications, technique, and adverse events for use of ESD and EFTR in the colon.
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Affiliation(s)
- Maham Hayat
- Section of Digestive Diseases and Nutrition, University of Oklahoma Health Sciences Center, 800 Stanton L Young Boulevard, Oklahoma City, OK 73104, USA
| | - Nabeel Azeem
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, MN 55455, USA
| | - Mohammad Bilal
- Division of Gastroenterology, Hepatology and Nutrition, University of Minnesota, Minneapolis, MN 55455, USA; Advanced Endoscopy, Division of Gastroenterology & Hepatology, Minneapolis Veterans Affairs Medical Center, 1 Veterans Drive, Minneapolis, MN 55417, USA.
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23
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Patient Selection, Risks, and Long-Term Outcomes Associated with Colorectal Polyp Resection. Gastrointest Endosc Clin N Am 2022; 32:351-370. [PMID: 35361340 DOI: 10.1016/j.giec.2021.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The 2 most significant complications of colonoscopy with polypectomy are bleeding and perforation. Although the incidence rates are generally low (<1%), these can be avoided by recognizing pertinent risk factors, which can be patient, polyp, and technique/device related. Endoscopists should be equipped to manage bleeding and perforation. Currently available devices and techniques to achieve hemostasis and manage colon perforations are reviewed.
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24
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Staudenmann D, Choi KKH, Kaffes AJ, Saxena P. Current endoscopic closure techniques for the management of gastrointestinal perforations. Ther Adv Gastrointest Endosc 2022; 15:26317745221076705. [PMID: 35252863 PMCID: PMC8891873 DOI: 10.1177/26317745221076705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 01/11/2022] [Indexed: 11/16/2022] Open
Abstract
Acute gastrointestinal perforations occur either from spontaneous or iatrogenic
causes. However, particular attention should be made in acute iatrogenic
perforations as timely diagnosis and endoscopic closure prevent morbidity and
mortality. With the increasing use of diagnostic endoscopy and advances in
therapeutic endoscopy worldwide, the endoscopist must be able to recognize and
manage perforations. Depending on the size and location of the defect, a variety
of endoscopic clips, stents, and suturing devices are available. This review
aims to prepare and guide the endoscopist to use the right tools and techniques
for optimal patient outcomes.
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Affiliation(s)
- Dominic Staudenmann
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Praxis Intesto, Bern, Switzerland; Université de Fribourg, Fribourg, Switzerland
| | - Kevin Kyung Ho Choi
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- The University of Sydney, Sydney, NSW, Australia
| | - Arthur John Kaffes
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- The University of Sydney, Sydney, NSW, Australia
| | - Payal Saxena
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, 50 Missenden Road, Sydney, NSW 2050, Australia
- The University of Sydney, Sydney, NSW, Australia
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Wang AY. Through-the-Scope Clips Are Indispensable in Treating Deep Mural Injury From Colorectal EMR. Clin Gastroenterol Hepatol 2022; 20:e19-e21. [PMID: 33609784 DOI: 10.1016/j.cgh.2021.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 02/12/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Andrew Y Wang
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia
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Mahmoud T, Wong Kee Song LM, Stavropoulos SN, Alansari TH, Ramberan H, Fukami N, Marya NB, Rau P, Marshall C, Ghandour B, Bejjani M, Khashab MA, Haber GB, Aihara H, Antillon-Galdamez MR, Chandrasekhara V, Abu Dayyeh BK, Storm AC. Initial multicenter experience using a novel endoscopic tack and suture system for challenging GI defect closure and stent fixation (with video). Gastrointest Endosc 2022; 95:373-382. [PMID: 34695421 DOI: 10.1016/j.gie.2021.10.018] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 10/12/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS Closure of endoscopic resection defects can be achieved with through-the-scope clips, over-the-scope clips, or endoscopic suturing. However, these devices are often limited by their inability to close large, irregular, and difficult-to-reach defects. Thus, we aimed to assess the feasibility and safety of a novel through-the-scope, suture-based closure system developed to overcome these limitations. METHODS This was a retrospective multicenter study involving 8 centers in the United States. Primary outcomes were feasibility and safety of early use of the device. Secondary outcomes were assessment of need for additional closure devices, prolonged procedure time, and technical feasibility of performing the procedure with an alternative device(s). RESULTS Ninety-three patients (48.4% women) with mean age 63.6 ± 13.1 years were included. Technical success was achieved in 83 patients (89.2%), and supplemental closure was required in 24.7% of patients (n = 23) with a mean defect size of 41.6 ± 19.4 mm. Closure with an alternative device was determined to be impossible in 24.7% of patients because of location, size, or shape of the defect. The use of the tack and suture device prolonged the procedure in 8.6% of cases but was considered acceptable. Adverse events occurred in 2 patients (2.2%) over a duration of follow-up of 34 days (interquartile range, 13-93.5) and were mild and moderate in severity. No serious adverse events or procedure-related deaths occurred. CONCLUSIONS The novel endoscopic through-the-scope tack and suture system is safe, efficient, and permits closure of large and irregularly shaped defects that were not possible with established devices.
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Affiliation(s)
- Tala Mahmoud
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Stavros N Stavropoulos
- Division of Gastroenterology and Hepatology, Department of Medicine, New York University School of Medicine-NYU Langone Hospital Long Island, Mineola, New York, USA
| | - Tarek H Alansari
- Division of Gastroenterology and Hepatology, Department of Medicine, New York University School of Medicine-NYU Langone Hospital Long Island, Mineola, New York, USA
| | | | - Norio Fukami
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Neil B Marya
- Division of Gastroenterology and Hepatology, UMASS Memorial Medical Center, Worchester, Massachusetts, USA
| | - Prashanth Rau
- Division of Gastroenterology and Hepatology, UMASS Memorial Medical Center, Worchester, Massachusetts, USA
| | - Christopher Marshall
- Division of Gastroenterology and Hepatology, UMASS Memorial Medical Center, Worchester, Massachusetts, USA
| | - Bachir Ghandour
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Michael Bejjani
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA
| | - Gregory B Haber
- Division of Gastroenterology, Center of Advanced Therapeutic and Innovation, NYU Langone Health, New York, New York, USA
| | - Hiroyuki Aihara
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Vinay Chandrasekhara
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Barham K Abu Dayyeh
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Andrew C Storm
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Outcomes of Deep Mural Injury After Endoscopic Resection: An International Cohort of 3717 Large Non-Pedunculated Colorectal Polyps. Clin Gastroenterol Hepatol 2022; 20:e139-e147. [PMID: 33422686 DOI: 10.1016/j.cgh.2021.01.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 12/31/2020] [Accepted: 01/05/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Although perforation is the most feared adverse event associated with endoscopic mucosal resection (EMR), limited data exists concerning its management. Therefore, we sought to evaluate the short- and long-term outcomes of intra-procedural deep mural injury (DMI) in an international multi-center observational cohort of large (≥20 mm) non-pedunculated colorectal polyps (LNPCPs). METHODS Consecutive patients who underwent EMR for a LNPCP ≥20 mm were evaluated. Significant DMI (S-DMI) was defined as Sydney DMI Classification type III (muscularis propria injury, target sign) or type IV/V (perforation without or with contamination, respectively). The primary outcome was successful S-DMI defect closure. Secondary outcomes included technical success (removal of all visible polypoid tissue during index EMR), surgical referral and recurrence at first surveillance colonscopy (SC1). RESULTS Between July 2008 to May 2020, 3717 LNPCPs underwent EMR. Median lesion size was 35mm (interquartile range (IQR) 25 to 45mm). Significant DMI was identified in 101 cases (2.7%), with successful defect closure in 98 (97.0%) using a median of 4 through-the-scope clips (TTSCs; IQR 3 to 6 TTSCs). Three (3.0%) patients underwent S-DMI-related urgent surgery. Technical success was achieved in 94 (93.1%) patients, with 46 (45.5%) admitted to hospital (median duration 1 day; IQR 1 to 2 days). Comparing LNPCPs with and without S-DMI, no differences in technical success (94 (93.1%) vs 3316 (91.7%); P = .62) or SC1 recurrence (12 (20.0%) vs 363 (13.6%); P = .15) were identified. CONCLUSIONS Significant DMI is readily managed endoscopically and does not appear to affect technical success or recurrence.
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Keihanian T, Othman MO. OverStitch Sx Endoscopic suturing system in minimally invasive endoscopic procedures: overview of its safety and efficacy and comparison to oversticth TM. Expert Rev Med Devices 2021; 19:11-23. [PMID: 34913782 DOI: 10.1080/17434440.2022.2019579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION OverStitch endoscopic suturing enables advanced closure by tissue approximation via endoscopically placed sutures with the ability to customize suture patterns. Newer OverStitch generation also known as OverStitch Sx overcame the limitation of the previous generation and is compatible with 20 single channel scopes over four platforms with greater maneuverability and visibility. AREAS COVERED In this article we will focus on the differences between three generations of OverStitch. In addition, we will review existing literature on the efficacy of OverStitch in the management of full thickness defect closure, fistula and leaks repair, stent fixation, and bariatric surgeries along with its complications and limitations. EXPERT OPINION Assembling overstitch takes less than five minutes and the correct sequence of system assembly is the key for a successful procedure. Transition from the second-generation OverStitch to OverStitch Sx may require three to five cases for learning curve.
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Affiliation(s)
- Tara Keihanian
- Division of Gastroenterology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Mohamed O Othman
- Gastroenterology and Hepatology Section, Baylor St Luke's Medical Center, Baylor College of Medicine, Houston, TX, USA
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Keihanian T, Othman MO. Colorectal Endoscopic Submucosal Dissection: An Update on Best Practice. Clin Exp Gastroenterol 2021; 14:317-330. [PMID: 34377006 PMCID: PMC8349195 DOI: 10.2147/ceg.s249869] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 07/17/2021] [Indexed: 12/13/2022] Open
Abstract
Endoscopic submucosal dissection (ESD) is a method of en-bloc resection of neoplastic colorectal lesions which is less invasive compared to surgical resection. Lesion stratification, architecture recognition and estimation of depth of invasion are crucial for patient selection. Expert endoscopists have integrated a variety of classification systems including Paris, lateral spreading tumor (LST), narrow band imaging (NBI), international colorectal endoscopic (NICE) and Japanese NBI expert team (JNET) in their day-to-day practice to enhance lesion detection accuracy. Major societies recommend ESD for LST-non granular (NG), Kudo-VI type, large depressed and protruded colonic lesions with shallow submucosal invasion. Chance of submucosal invasion enhances with increased depth as well as tumor location and size. In comparison to endoscopic mucosal resection (EMR), ESD has a lowerl recurrence rate and higher curative resection rate, making it superior for larger colonic lesions management. Major complications such as bleeding and perforation could be seen in up to 11% and 16% of patients, respectively. In major Western countries, performing ESD is challenging due to limited number of expert providers, lack of insurance coverage, and unique patient characteristics such as higher BMI and higher percentage of previously manipulated lesions.
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Affiliation(s)
- Tara Keihanian
- Division of Gastroenterology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Mohamed O Othman
- Gastroenterology and Hepatology Section, Baylor College of Medicine, Houston, TX, USA
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Granata A, Martino A, Ligresti D, Zito FP, Amata M, Lombardi G, Traina M. Closure techniques in exposed endoscopic full-thickness resection: Overview and future perspectives in the endoscopic suturing era. World J Gastrointest Surg 2021; 13:645-654. [PMID: 34354798 PMCID: PMC8316845 DOI: 10.4240/wjgs.v13.i7.645] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 03/29/2021] [Accepted: 06/16/2021] [Indexed: 02/06/2023] Open
Abstract
Exposed endoscopic full-thickness resection (EFTR) without laparoscopic assistance is a minimally invasive natural orifice transluminal endoscopic surgery technique that is emerging as a promising effective and safe alternative to surgery for the treatment of muscularis propria-originating gastric submucosal tumors. To date, various techniques have been used for the closure of the transmural post-EFTR defect, mainly consisting in clip- and endoloop-assisted closure methods. However, the recent advent of dedicated tools capable of providing full-thickness defect suture could further improve the efficacy and safety of the exposed EFTR procedure. The aim of our review was to evaluate the efficacy and safety of the different closure methods adopted in gastric-exposed EFTR without laparoscopic assistance, also considering the recent advent of flexible endoscopic suturing.
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Affiliation(s)
- Antonino Granata
- Digestive Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS–ISMETT, Palermo 90127, Italy
| | - Alberto Martino
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Dario Ligresti
- Digestive Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS–ISMETT, Palermo 90127, Italy
| | - Francesco Paolo Zito
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Michele Amata
- Digestive Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS–ISMETT, Palermo 90127, Italy
| | - Giovanni Lombardi
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli 80131, Italy
| | - Mario Traina
- Digestive Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS–ISMETT, Palermo 90127, Italy
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Granata A, Martino A, Amata M, Ligresti D, Traina M. Gastrointestinal exposed endoscopic full-thickness resection in the era of endoscopic suturing: a retrospective single-center case series. Wideochir Inne Tech Maloinwazyjne 2021; 16:321-328. [PMID: 34136027 PMCID: PMC8193753 DOI: 10.5114/wiitm.2021.104496] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 10/26/2020] [Indexed: 12/24/2022] Open
Abstract
INTRODUCTION Exposed endoscopic full thickness resection (EFTR) is a minimally invasive technique that has shown promising efficacy and safety in the removal of both gastrointestinal (GI) submucosal tumors (SMTs) arising from the muscularis propria (MP) and select epithelial tumors (ETs) unsuitable for conventional resection techniques. Given the chance of realizing endosurgical full-thickness suturing, the Endoscopic Suturing System (ESS) can be used to close wall defects in this setting. However, data concerning its use in EFTR are still limited. AIM This study was conducted to evaluate the safety and efficacy of exposed EFTR with defect closure using the ESS for the removal of both GI SMTs and select ETs unsuitable for conventional resection techniques. MATERIAL AND METHODS This was a retrospective, single-center, observational cohort study of patients who underwent GI exposed EFTR. RESULTS Seven patients (M : F 6 : 1) with a mean age of 56 ±14.5 years were identified. The indications were MP-originating SMTs of the stomach (n = 2) and duodenum (n = 2), and from submucosa of the rectum (n = 1), and 2 ETs of the rectum. Exposed EFTR and defect closure were successfully performed in 6/7 patients. One case was converted to laparoscopic gastric wedge resection due to technical unfeasibility. We performed an R0 resection in all cases, with the exception of 1 case of rectal EFTR. No macroscopic recurrence was detected at 6-month endoscopic follow-up. CONCLUSIONS GI exposed EFTR with defect closure by the ESS appears to be feasible, effective, and safe in referral centers. Further studies are necessary to clarify the role of the ESS for post-EFTR wall defect closure.
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Affiliation(s)
- Antonino Granata
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS – ISMETT, Palermo, Italy
| | - Alberto Martino
- Department of Gastroenterology and Digestive Endoscopy, AORN “Antonio Cardarelli”, Napoli, Italy
| | - Michele Amata
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS – ISMETT, Palermo, Italy
| | - Dario Ligresti
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS – ISMETT, Palermo, Italy
| | - Mario Traina
- Endoscopy Service, Department of Diagnostic and Therapeutic Services, IRCCS – ISMETT, Palermo, Italy
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Uraoka T, Yunoki S, Kinoshita S, Takatori Y, Hirai Y, Tanaka H, Narita T, Shimoda M. Novel temperature-responsive, biodegradable and injectable collagen sol for the endoscopic closure of colonic perforation holes: Animal study (with videos). Dig Endosc 2021; 33:616-620. [PMID: 32794223 DOI: 10.1111/den.13810] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 08/07/2020] [Accepted: 08/11/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Endoscopic submucosal dissection (ESD) poses a risk of intraprocedural perforation. We have developed a biodegradable injectable collagen sol that undergoes a liquid-to-gel formation in response to body temperature. Here, we investigated the feasibility of this novel collagen sol for the endoscopic closure of iatrogenic perforation holes. METHODS In two experiments, 12 and 5 colonic perforation holes (3-5 mm) were made using an ESD knife in four and three live pigs under general anesthesia, respectively. In Experiment 1, collagen sol was delivered to the perforation holes using an endoscopic catheter. When the colon was expanded by CO2 insufflation, endo-clips were applied to the perforation holes. For Experiment 2, Collagen sol adjusted based on the Experiment 1 results was delivered to the perforation holes in the same manner. A leak test was performed for every colon after the pigs were killed, and the histology of the perforation sites was evaluated. RESULTS In both experiments, collagen sol was smoothly delivered to the target area and fixed as a gel on the perforation holes. Experiment 1, 83% (10/12) of the perforation holes were completely closed, and all endo-clips were placed with composure. Experiment 2, all perforation holes were completely closed with collagen gel. There was no leak from the perforation holes. Histology revealed a fixation of the collagen gel as an embolus agent in the perforation holes. CONCLUSIONS This novel collagen sol may be used for the endoscopic closure of intraprocedural perforation. Further studies will determine this collagen sol's clinical feasibility and safety.
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Affiliation(s)
- Toshio Uraoka
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, Gumma, Japan.,Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Shunji Yunoki
- Biotechnology Group, Tokyo Metropolitan Industrial Technology Research Institute, Tokyo, Japan
| | - Satoshi Kinoshita
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Yusaku Takatori
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Yuichiro Hirai
- Department of Gastroenterology, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Hirohito Tanaka
- Department of Gastroenterology and Hepatology, Gunma University Graduate School of Medicine, Gumma, Japan
| | - Takefumi Narita
- Biotechnology Group, Tokyo Metropolitan Industrial Technology Research Institute, Tokyo, Japan
| | - Masayuki Shimoda
- Department of Pathology, School of Medicine, Keio University, Tokyo, Japan
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Zhang W, Sun G, Zhang H, Furnee E, Liu Q, Gong H, Sun P, Zhang W. Endoscopic closure of a postoperative rectal anastomotic leakage with hemoclips: A case report. Int J Surg Case Rep 2021; 80:105525. [PMID: 33592425 PMCID: PMC7893441 DOI: 10.1016/j.ijscr.2021.01.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 01/05/2021] [Accepted: 01/08/2021] [Indexed: 12/14/2022] Open
Abstract
The hemoclip device is effective and safe for endoscopic closure of the anastomotic leakage after low anterior resection. Hemoclip device reduce costs as well as avoid an additional operation for the patient. Strict criteria should be applied when identifying suitable patients.
Introduction and importance Hemoclips have been used to protect leakage after endoscopic resection of large colorectal polyps or early-staged rectal cancer, or for perforation of the sigmoid colon during colonoscopy. However, endoscopic clips were seldom used to manage anastomotic leakage after low anterior resection of rectal cancer. Case presentation A patient with postoperative anastomotic leakage after low anterior resection for rectal cancer was successfully treated by endoscopic hemoclips under colonoscopic vision after failure of conservative treatment. Postoperative course was uncomplicated and the patient was discharged from the hospital seven days later. Clinical discussion and conclusion Endoscopic hemoclips should be considered as an alternative option for the treatment of an anastomotic leakage in cases where conservative treatment has failed. As they are safe and effective for closure, however good bowel preparation and strict inclusion criteria are required.
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Affiliation(s)
- Wei Zhang
- Department of Gastrointestinal Surgery, Henan Province People's Hospital, China
| | - Ge Sun
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China; Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Hang Zhang
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China
| | - Edgar Furnee
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Qizhi Liu
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China
| | - Haifeng Gong
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China
| | - Peichun Sun
- Department of Gastrointestinal Surgery, Henan Province People's Hospital, China.
| | - Wei Zhang
- Department of Colorectal Surgery, Changhai Hospital, Shanghai, China.
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Endoscopic Diagnosis and Management of Gastrointestinal Trauma. Clin Gastroenterol Hepatol 2021; 19:14-23. [PMID: 31605872 DOI: 10.1016/j.cgh.2019.09.048] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 09/28/2019] [Indexed: 02/07/2023]
Abstract
Trauma affects all sociodemographic profiles and is a major cause of morbidity and mortality particularly in patients less than forty years of age. A variety of endoscopic tools and techniques initially used for iatrogenic etiologies (post-operative bile or pancreatic duct leaks, intra-procedural perforation) have been adopted for use in the gastrointestinal trauma victim. The purpose of this review is to highlight a variety of gastrointestinal traumatic complications where endoscopy can serve a complement and/or definitive management strategy.
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Kumar S, Youn YH, Lee JH. Life on a knife edge: the optimal approach to the management of perforations during endoscopic submucosal dissection (ESD). Expert Rev Gastroenterol Hepatol 2020; 14:965-973. [PMID: 32658593 DOI: 10.1080/17474124.2020.1791085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Endoscopic submucosal dissection (ESD) is a well-established procedure that can provide curative resection of malignant and premalignant lesions endoscopically, thereby offering patients an effective non-operative option. Though ESD is safe and highly effective when performed in appropriately selected patients by an experienced ESD expert, it carries risks including intraprocedural and delayed perforation. AREAS COVERED This review provides a practical approach to the initial management of perforation to minimize subsequent complications. The importance of prompt recognition of perforation and early intervention cannot be overstated. This review summarizes indications for closure, anatomic considerations impacting closure, and closure techniques. This article also highlights the do's and don'ts of various closure devices, focusing particularly on advanced closure methods, the-over-the-scope clips (OTSCs) and endoscopic suturing. EXPERT OPINION As ESD offers surgery-sparing alternatives to patients, advanced closure techniques allow endoscopists to effectively and promptly manage associated complications, improving the possibility of the widespread implementation of ESD in the US. With continued improvements in OTSCs and endoscopic suturing, ESD will become a stalwart of endoscopic management of malignant and premalignant gastrointestinal lesions.
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Affiliation(s)
- Shria Kumar
- Division of Gastroenterology, Perelman School of Medicine at the University of Pennsylvania , Philadelphia, PA, USA
| | - Young Hoon Youn
- Department of Gastroenterology, Yonsei University College of Medicine , Seoul, Korea
| | - Jeffrey H Lee
- Department of Gastroenterology, Hepatology, and Nutrition, MD Anderson Cancer Center , Houston, TX, USA
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Paspatis GA, Arvanitakis M, Dumonceau JM, Barthet M, Saunders B, Turino SY, Dhillon A, Fragaki M, Gonzalez JM, Repici A, van Wanrooij RLJ, van Hooft JE. Diagnosis and management of iatrogenic endoscopic perforations: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement - Update 2020. Endoscopy 2020; 52:792-810. [PMID: 32781470 DOI: 10.1055/a-1222-3191] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
1: ESGE recommends that each center implements a written policy regarding the management of iatrogenic perforations, including the definition of procedures that carry a higher risk of this complication. This policy should be shared with the radiologists and surgeons at each center. 2 : ESGE recommends that in the case of an endoscopically identified perforation, the endoscopist reports its size and location, with an image, and statement of the endoscopic treatment that has been applied. 3: ESGE recommends that symptoms or signs suggestive of iatrogenic perforation after an endoscopic procedure should be rapidly and carefully evaluated and documented with a computed tomography (CT) scan. 4 : ESGE recommends that endoscopic closure should be considered depending on the type of the iatrogenic perforation, its size, and the endoscopist expertise available at the center. Switch to carbon dioxide (CO2) endoscopic insufflation, diversion of digestive luminal content, and decompression of tension pneumoperitoneum or pneumothorax should also be performed. 5 : ESGE recommends that after endoscopic closure of an iatrogenic perforation, further management should be based on the estimated success of the endoscopic closure and on the general clinical condition of the patient. In the case of no or failed endoscopic closure of an iatrogenic perforation, and in patients whose clinical condition is deteriorating, hospitalization and surgical consultation are recommended.
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Affiliation(s)
- Gregorios A Paspatis
- Gastroenterology Department, Venizelion General Hospital, Heraklion, Crete-Greece
| | - Marianna Arvanitakis
- Gastroenterology, Hepatopancreatology, and Digestive Oncology, Erasme Hospital, Universite Libre de Bruxelles, Brussels, Belgium
| | - Jean-Marc Dumonceau
- Gastroenterology Service, Centre Hospitalier Universitaire de Charleroi, Charleroi, Belgium
| | | | - Brian Saunders
- St Mark's Hospital, Wolfson Unit for Endoscopy, North West London Hospitals University Trust, Harrow, London, UK
| | | | - Angad Dhillon
- St Mark's Hospital, Wolfson Unit for Endoscopy, North West London Hospitals University Trust, Harrow, London, UK
| | - Maria Fragaki
- Gastroenterology Department, Venizelion General Hospital, Heraklion, Crete-Greece
| | | | - Alessandro Repici
- Department of Gastroenterology, Digestive Endoscopy Unit, IRCCS Istituto Clinico Humanitas, Milan, Italy
| | - Roy L J van Wanrooij
- Department of Gastroenterology and Hepatology, AG&M Research Institute, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, The Netherlands
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Abstract
PURPOSE OF REVIEW To discuss endoscopic resection techniques of early gastrointestinal malignancy. The review will focus on the indications and outcomes of endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). RECENT FINDINGS EMR is indicated for upper GI lesions less than 20 mm provided they can be easily lifted and have a low risk of submucosal invasion (SMI). ESD should be considered for esophageal and gastric lesions that are bulky, show intramucosal carcinoma, or have a risk of superficial submucosal invasion. With regard to colonic polyps, EMR is acceptable for the removal of large colonic polyps using a piecemeal technique. ESD can be reserved for rectal neuroendocrine tumors, fibrotic polyps, or polyps harboring early malignancy. In selected cases, particularly in lesions less than 2 cm in size, EMR can be safe and effective. For larger lesions or lesions with submucosal invasion, ESD is effective and curative. Choosing the best approach can be tailored for each patient depending on lesion size, pathology, and availability of local expertise.
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Affiliation(s)
- Yahya Ahmed
- Baylor St Luke's Medical Center, Houston, TX, USA
| | - Mohamed Othman
- Baylor St Luke's Medical Center, Houston, TX, USA. .,Division of Gastroenterology, Baylor College of Medicine, 7200 Cambridge St., 8th Floor, Suite 8B, Houston, TX, 77030, USA.
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Kantsevoy SV. Duodenal endoscopic submucosal dissection: Is it ready for primetime? (with video). Gastrointest Endosc 2020; 91:1138-1139. [PMID: 32327121 DOI: 10.1016/j.gie.2020.02.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 02/17/2020] [Indexed: 02/08/2023]
Affiliation(s)
- Sergey V Kantsevoy
- Institute for Digestive Health and Liver Diseases, Mercy Medical Center, Baltimore, Maryland, USA; University of Maryland School of Medicine, Baltimore, Maryland, USA
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Kaltenbach T, Anderson JC, Burke CA, Dominitz JA, Gupta S, Lieberman D, Robertson DJ, Shaukat A, Syngal S, Rex DK. Endoscopic Removal of Colorectal Lesions-Recommendations by the US Multi-Society Task Force on Colorectal Cancer. Gastrointest Endosc 2020; 91:486-519. [PMID: 32067745 DOI: 10.1016/j.gie.2020.01.029] [Citation(s) in RCA: 82] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Tonya Kaltenbach
- Veterans Affairs San Francisco, University California-San Francisco, San Francisco, California.
| | - Joseph C Anderson
- Veterans Affairs Medical Center, White River Junction, Vermont; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; University of Connecticut Health Center, Farmington, Connecticut
| | - Carol A Burke
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, Ohio
| | - Jason A Dominitz
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington; University of Washington School of Medicine, Seattle, Washington
| | - Samir Gupta
- Veterans Affairs San Diego Healthcare System, San Diego, California; University of California-San Diego, San Diego, California
| | | | - Douglas J Robertson
- Veterans Affairs Medical Center, White River Junction, Vermont; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Aasma Shaukat
- Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota; University of Minnesota, Minneapolis, Minnesota
| | - Sapna Syngal
- Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, Massachusetts
| | - Douglas K Rex
- Indiana University School of Medicine, Indianapolis, Indiana
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Endoscopic Removal of Colorectal Lesions: Recommendations by the US Multi-Society Task Force on Colorectal Cancer. Am J Gastroenterol 2020; 115:435-464. [PMID: 32058340 DOI: 10.14309/ajg.0000000000000555] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Kaltenbach T, Anderson JC, Burke CA, Dominitz JA, Gupta S, Lieberman D, Robertson DJ, Shaukat A, Syngal S, Rex DK. Endoscopic Removal of Colorectal Lesions-Recommendations by the US Multi-Society Task Force on Colorectal Cancer. Gastroenterology 2020; 158:1095-1129. [PMID: 32122632 DOI: 10.1053/j.gastro.2019.12.018] [Citation(s) in RCA: 161] [Impact Index Per Article: 40.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Tonya Kaltenbach
- Veterans Affairs San Francisco, University California-San Francisco, San Francisco, California.
| | - Joseph C Anderson
- Veterans Affairs Medical Center, White River Junction, Vermont; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire; University of Connecticut Health Center, Farmington, Connecticut
| | - Carol A Burke
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, Ohio
| | - Jason A Dominitz
- Veterans Affairs Puget Sound Health Care System, Seattle, Washington; University of Washington School of Medicine, Seattle, Washington
| | - Samir Gupta
- Veterans Affairs San Diego Healthcare System, San Diego, California; University of California-San Diego, San Diego, California
| | | | - Douglas J Robertson
- Veterans Affairs Medical Center, White River Junction, Vermont; Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
| | - Aasma Shaukat
- Minneapolis Veterans Affairs Health Care System, Minneapolis, Minnesota; University of Minnesota, Minneapolis, Minnesota
| | - Sapna Syngal
- Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, Massachusetts
| | - Douglas K Rex
- Indiana University School of Medicine, Indianapolis, Indiana
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Resection of the gastric submucosal tumor (G-SMT) originating from the muscularis propria layer: comparison of efficacy, patients' tolerability, and clinical outcomes between endoscopic full-thickness resection and surgical resection. Surg Endosc 2020; 34:4053-4064. [PMID: 32016516 PMCID: PMC7394934 DOI: 10.1007/s00464-019-07311-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Accepted: 11/28/2019] [Indexed: 02/06/2023]
Abstract
Background and aims Endoscopic full-thickness resection (EFTR) has been increasingly applied in the treatment of gastric submucosal tumors (G-SMTs) with explorative intention. This study aimed to compare the efficacy, tolerability, and clinical outcomes of EFTR and surgical intervention for the management of muscularis propria (MP)-derived G-SMTs. Methods Between September 2011 and May 2019, the clinical records of patients with MP-derived G-SMTs undergoing EFTR at our endoscopic unit were collected. A cohort of people with primary MP-derived G-SMTs treated by surgery was matched in a 1:1 ratio to EFTR group with regard to patients’ baseline characteristics, clinicopathologic features of the tumor and the procedure date. The perioperative outcomes and follow-up data were analyzed. Results In total, 62 and 62 patients were enrolled into the surgery and EFTR group, respectively, with median follow-up of 786 days. The size of G-SMTs (with ulceration) ranged from 10 to 90 mm. For patients with tumor smaller than 30 mm, surgery and EFTR group presented comparable procedural success rate (both were 100%), en bloc resection rate (100% vs. 94.7%), tumor capsule rupture rate (0% vs. 5.3%), and pathological R0 resection rate (both were 100%). EFTR had a statistically significant advantage over surgery for estimated blood loss (3.12 ± 5.20 vs. 46.97 ± 60.73 ml, p ≤ 0.001), discrepancy between the pre- and postprocedural hemoglobin level (5.18 ± 5.43 vs. 9.84 ± 8.25 g/L, p = 0.005), bowel function restoration [1 (0–5) vs. 3 (1–5) days, p ≤ 0.001], and hospital cost (28,617.09 ± 6720.78 vs. 33,963.10 ± 13,454.52 Yuan, p = 0.033). The patients with tumor larger than 30 mm showed roughly the same outcomes after comparison analysis of the two groups. However, the clinical data revealed lower en bloc resection rate (75.0% vs. 100%, p = 0.022) and higher tumor capsule rupture rate (25.0% vs. 0%, p = 0.022) for EFTR when compared to surgery. The procedure time, duration of postprocedural fasting and antibiotics usage, and hospital stay of the two groups were equivalent. The occurrence rate of adverse events within postoperative day 7 were 74.2% and 72.6% after EFTR and surgery, respectively (p = 1.000). No complications occurred during the follow-up. Conclusion For treatment of MP-derived G-SMTs (with or without ulceration), our study showed the feasibility and safety of EFTR, which also provided better results in terms of procedural blood loss, the postoperative bowel function restoration and cost-effectiveness when compared to surgery, whereas the surgery was superior in en bloc resection rate for G-SMTs larger than 30 mm. The postprocedural clinical outcomes seemed to be equivalent in these two resection methods.
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Ge PS, Thompson CC. The Use of the Overstitch to Close Perforations and Fistulas. Gastrointest Endosc Clin N Am 2020; 30:147-161. [PMID: 31739961 PMCID: PMC6885379 DOI: 10.1016/j.giec.2019.08.010] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Endoscopic suturing allows for select patients with perforations, leaks, and fistulas to be managed endoscopically. Experience with the Overstitch endoscopic suturing device suggests it may be superior to endoclips in the management of perforations, because of its ability to achieve full-thickness suturing and create an airtight closure. Although successful closure of leaks and fistulas using the Overstitch device has been described, additional therapy with a multimodality approach is often required because of inherent challenges with fistula recurrence. This article reviews the existing literature on the Overstitch endoscopic suturing system specifically in the management of gastrointestinal perforations, leaks, and fistulas.
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Affiliation(s)
- Phillip S. Ge
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1466, Houston, TX 77030-4009, USA
| | - Christopher C. Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, 75 Francis Street, Boston, MA 02115, USA,Corresponding author. twitter: @MetabolicEndo (C.C.T.)
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Kolb JM, Hammad H. The Use of the Overstitch to Close Endoscopic Resection Defects. Gastrointest Endosc Clin N Am 2020; 30:163-171. [PMID: 31739962 PMCID: PMC7202237 DOI: 10.1016/j.giec.2019.08.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Endoscopic resection of luminal gastrointestinal neoplasia offers a minimally invasive, lower risk alternative that can be successful in the appropriate setting. Bleeding and perforation can occur with endoscopic mucosal resection and endoscopic submucosal dissection. Defect closure with conventional endoclips or modified technique using endoloops can decrease the risk of adverse events. The Overstitch (Apollo Endosurgery, Austin, TX) endoscopic suturing device is designed for tissue apposition and thus can effectively close a large resection defect. Herein we describe our technique. Our and other groups' initial experience with suturing for closure of the resection defect demonstrates high procedural success rates and safety.
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Yu JX, Schulman AR. Complications of the Use of the OverStitch Endoscopic Suturing System. Gastrointest Endosc Clin N Am 2020; 30:187-195. [PMID: 31739964 DOI: 10.1016/j.giec.2019.09.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Endoscopic suturing with the OverStitch device is safe and effective for a wide range of applications from defect closure and stent fixation to hemostasis and bariatrics. OverStitch-related complications remain rare, although adverse events such as bleeding, mucosal injury, perigastric fluid collections, leaks, and perforations have been reported. Provider familiarity with the device and the specific pitfalls that may arise with OverStitch use in different situations is necessary to minimize the risk of adverse events. This article reviews potential complications and provides tips and troubleshooting techniques.
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Affiliation(s)
- Jessica X Yu
- Division of Gastroenterology and Hepatology, University of Michigan, 1301 Catherine Street, Ann Arbor, MI 48109, USA.
| | - Allison R Schulman
- Division of Gastroenterology and Hepatology, University of Michigan, 1301 Catherine Street, Ann Arbor, MI 48109, USA
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Gabr A. Sealing the hole: endoscopic management of acute gastrointestinal perforations. Frontline Gastroenterol 2020; 11:55-61. [PMID: 31885841 PMCID: PMC6914298 DOI: 10.1136/flgastro-2018-101136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 02/03/2019] [Accepted: 02/16/2019] [Indexed: 02/04/2023] Open
Abstract
Acute perforations are one of the recognised complications of both diagnostic and therapeutic gastrointestinal (GI) endoscopy. The incidence rate varies according to the type of procedure and the anatomical location within the GI tract. For decades, surgical treatment has been the standard of care, but endoscopic closure has become a more popular approach, due to feasibility and the reduction of the burden of surgery. Various devices are available now such as through-the-scope clips, over-the-scope clips, endoscopic suturing devices, stents, bands and omental patch. All have been tested in studies done on humans or animal models, with a reasonable overall technical and clinical success rate, proving efficiency and feasibility of endoscopic closure. The choice of which device to use depends on the site and the size of the perforation. It also depends on availability of thee device and the endoscopist's experience. A number of factors that could predict success of endoscopic closure or favour surgical treatment have been suggested in different studies. After successful endoscopic closure, patients are usually kept nil by mouth and receive antibiotics for a duration that varied between different studies.
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Affiliation(s)
- Ahmed Gabr
- Gastroenterology, Palestine Hospital, Cairo, Egypt
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De Moura DTH, Baptista A, Jirapinyo P, De Moura EGH, Thompson C. Role of Cardiac Septal Occluders in the Treatment of Gastrointestinal Fistulas: A Systematic Review. Clin Endosc 2020; 53:37-48. [PMID: 31286746 PMCID: PMC7003006 DOI: 10.5946/ce.2019.030] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 02/21/2019] [Accepted: 02/24/2019] [Indexed: 02/06/2023] Open
Abstract
Treating gastrointestinal (GI) fistulas endoscopically is challenging owing to an established epithelial tract. The variety of endoscopic approaches is transforming endoscopy into a first-line therapy. However, many sessions are often required, with variable success rates. Owing to these limitations, the off-label use of cardiac septal occluders (CSOs) has been reported. We searched for articles related to CSOs in the MEDLINE, EMBASE, Cochrane Library, and LILACS databases and gray literature. The primary outcomes included technical success, clinical success, and safety of CSOs in GI fistula management. A total of 25,574 records were identified, and 19 studies ultimately satisfied the inclusion criteria. Technical success was achieved in all cases. Of the 22 fistulas, 77.27% had successful closure, with a mean follow-up period of 32.02 weeks. The adverse event rate was 22.72%, with no associated mortality. Univariable and multivariable regression analyses showed no significant difference in the success of closure and adverse events in relation to several variables among the subgroups. The use of CSOs appeared to be technically feasible, effective, and safe in the treatment of GI fistulas. The satisfactory results derived from this sparse literature suggest that it can be an option in the management of GI fistulas.
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Affiliation(s)
- Diogo Turiani Hourneaux De Moura
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brasil
| | - Alberto Baptista
- Hospital das Clínicas Caracas, Unidad de Exploraciones Digestivas, Caracas, Venezuela
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Abstract
Endoscopic suturing device for flexible endoscopy was conceptualized by Apollo Group in collaboration with Olympus Optical Ltd. The first modification of suturing device for flexible endoscopy (Eagle Claw) was manufactured by Olympus engineers and extensively used by members of Apollo Group in numerous bench-top experiments on isolated pig stomachs and in live porcine model. The suturing system for flexible endoscopy in humans (Overstitch) was cleared for general clinical use in the United States in 2008. The latest model is compatible with more than 20 single-channel flexible endoscopes with diameters ranging from 8.8 mm to 9.8 mm made by major endoscope manufacturers.
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Abstract
Large and complex colon polyps are frequently referred to surgery for fear of perforation that may need emergency surgery. During the last 15 years, advances in clip and suturing devices allowed us to close perforations and avoid surgery. In addition, we have made substantial progress in our understanding of the lesions at risk for either immediate or delayed perforation. This article focuses on the colonoscopic closure of resection defects and perforations and the prevention and treatment of colon perforations after endoscopic resection.
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Wickham C, Mirza KL, Lee SW. Management of colonoscopic perforation. SEMINARS IN COLON AND RECTAL SURGERY 2019. [DOI: 10.1016/j.scrs.2019.100686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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