Endoscopic closure after intraluminal surgery

Association between prophylactic closure of mucosal defect and delayed adverse events after endoscopic resection: a systematic review and meta-analysis

OBJECTIVE

To investigate the potential of prophylactic closure of mucosal defects to prevent adverse events following endoscopic resection of superficial layers of the gastrointestinal (GI) wall.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

We searched PubMed, Embase, Web of Science and the Cochrane Library for studies eligible for inclusion in our meta-analysis from inception to February 2022.

DATA EXTRACTION AND SYNTHESIS

We compared the effects of closure versus non-closure of mucosal defects with respect to adverse events including delayed bleeding, delayed perforation and postpolypectomy coagulation syndrome (PPCS). We used a random-effects model for all analyses. Subgroup analyses were performed based on gastrointestinal sites, surgical procedures and study designs.

RESULTS

In total, this study includes 11 383 patients from 28 studies. For delayed bleeding, closure group was associated with a lower incidence (Risk Ratio [RR]: 0.40, 95% Confidence interval [CI]: 0.30 to 0.53, p<0.001; I2=25%) and consistent results were observed in the subgroups. Also, for delayed perforation, a combined analysis of all sites and surgical methods showed a protective effect of prophylactic closure of mucosal defects (RR: 0.42, 95% CI: 0.22 to 0.82, p=0.01; I2=0%). Similar results were observed in the subgroup analyses, despite the wide CIs. Regarding the PPCS, neither the pooled RRs nor the subgroup analyses showed significant differences.

CONCLUSION

Prophylactic closure of mucosal defects is beneficial in reducing the incidence of delayed bleeding and delayed perforation after endoscopic resection, but there is no significant difference in reducing the incidence of PPCS.

Clinical utility of a novel anchor pronged clip for mucosal defect closure after colorectal endoscopic submucosal dissection (with video)

Background and study aims The MANTIS Clip (Boston Scientific) is a novel anchor pronged clip designed to enhance tissue grasping and facilitate the closure of defects in the gastrointestinal tract. This study evaluates the feasibility and effectiveness of the MANTIS Clip for closing mucosal defects following colorectal endoscopic submucosal dissection (C-ESD). Patients and methods A retrospective single-center study was conducted on patients who underwent C-ESD with MANTIS Clip closure from May 2023 to April 2024. The primary outcome measured was the complete closure success rate. Secondary outcomes included defect size, sustained closure rate, closure time, number of clips used, adverse events (AEs), and hospital stay duration. Results The MANTIS Clip was used in 52 cases. The complete closure rate was 98.1% (51/52), with a sustained closure rate of 96.1% (49/51). The median closed defect size was 32 mm, with the largest being 62 mm. The median closure time was 8 minutes. Typically, one MANTIS Clip per defect was used, with only one lesion requiring two clips. The median number of additional clips used was seven. AEs included one case of bleeding (1.9%) and one case of post-ESD coagulation syndrome (1.9%), both managed without extending hospital stays. The median C-reactive protein level on the first day post-ESD was 0.35 mg/dL and the median hospital stay was 5 days. Conclusions The MANTIS Clip is effective and practical for mucosal defect closure post-C-ESD, demonstrating high success and sustained closure rates with minimal complications. Future multicenter randomized trials are needed to further assess its efficacy and safety.

Loop9 closure technique for mucosal defects after colorectal endoscopic submucosal dissection (with video)

Background and study aims Mucosal defect closure after colorectal endoscopic submucosal dissection (ESD) has the potential to reduce the occurrence of delayed adverse events (AEs) such as bleeding and perforation. This study aimed to assess the feasibility and effectiveness of the Loop9 method for closing mucosal defects following colorectal ESD. Patients and methods A retrospective single-center study was conducted using prospectively collected data from May 2020 to March 2023. Loop9 was deployed through a single instrument channel and anchored with clips at the defect site. Closure was accomplished by tightening the loop and deploying additional conventional clips as needed for complete closure. The primary outcome was complete closure rate, with secondary outcomes including the sustained closure rate at 4 to 5 days post-ESD, closed defect size, closure time, number of additional clips, and incidence of delayed AEs. Results This study included 118 cases. Complete closure was achieved in 96.6% of cases (114/118) with a sustained closure rate of 93.9% (107/114). The median size of the closed mucosal defects was 30 mm (interquartile range [IQR]: 25-38, range: 15-74). The median closure time was 14 minutes (IQR: 11.25-17), and the median number of additional clips deployed was six (IQR: 4-7). Stenosis requiring balloon dilatation was observed in one patient; however, there were no instances of post-ESD bleeding or delayed perforation. Conclusions The Loop9 method proved feasible and effective for closing mucosal defects following colorectal ESD, achieving high rates of complete and sustained closure.

Endoscopic ligation technique for refractory gastrotracheal fistula

Endoscopic therapy has recently undergone remarkable progress, including the use of suturing procedures within the gastrointestinal tract using flexible endoscopes. However, existing suturing techniques primarily involve closure using instruments or continuous sutures using an endoscopic needle holder, leaving a gap in nodal suturing methods with extracorporeal ligation. This paper introduces a novel approach, the endoscopic ligation technique, wherein a flexible endoscope is utilized for nodal suturing through extracorporeal ligation.

The value of single-channel endoscopic traction and kiss suture technique in closing wounds caused by endoscopic resection of gastrointestinal muscularis propria tumors

BACKGROUND

To investigate the value of single forceps endoscopic traction stapling suture technique (SFETSST) in closing wounds caused by endoscopic resection of gastrointestinal muscularis propria tumor (GMPT).

METHODS

Consecutive patients who underwent submucosal tumor excavation (ESE) and endoscopic full-thickness resection (EFR) for GMPT in the Second Affiliated Hospital of Xiamen Medical College from January 2015 to January 2022 were retrospectively collected. They were divided into the SFETSST group and the standard group (patients who receive single forceps traction-free endoscopic suture technique). The healing effects were compared between the two groups.

RESULTS

Seventy-seven patients were included in our study with 50 patients included in SFETSST group. The baseline characteristics had no significant difference between the two groups. The technical success rate of wound suture in SFETSST cluster was significantly upper than that within standard cluster (100% vs. 88.89%, P = 0.04). The wound suture time in SFETSST cluster was significantly lower than that within standard cluster (33.19 ± 10.64 min, P < 0.001). Moreover, the incidence rates of intra-operative and postoperative complications in SFETSST cluster were lower than standard cluster (0 vs. 7.41%, P = 0.051 and 0 vs. 11.11%, P = 0.016). Interestingly, the SFETSST cluster had lower cost of consumables (2485.40 ± 591.78 vs. 4098.52 ± 1903.06 Yuan, P = 0.01) and shorter hospital stay (4.96 ± 0.90 vs. 7.19 ± 2.45, P < 0.001) than standard cluster.

CONCLUSION

Our study showed that to fully closure the full-thickness defects of digestive tract, SFETSST was effective, safe, and economical, which was worth popularizing.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Clip stopper closure method using a detachable snare in combination with ZEOCLIP for endoscopic submucosal dissection-induced mucosal defects

Endoscopic submucosal dissection (ESD) is globally performed to treat early epithelial tumors of the gastrointestinal tract, but delayed perforation is a problematic procedure-related complication. To address this problem, closure of ESD-induced mucosal defects with a detachable snare has been reported. However, one problem is that this method usually requires some degree of skill and replacing a single-channel scope with a two-channel scope. We developed the clip stopper closure (CSC) method using a detachable snare in combination with the ZEOCLIP, which can be easily performed with a single-channel scope, for ESD-induced mucosal defects. Six consecutive cases were treated with this closure method for colonic ESD-induced mucosal defects. The median closure time was 12.5 (10-24) min, and the success rate of this procedure was 100%. Our CSC method was able to be performed in any part of the colon. In conclusion, the CSC method using a detachable snare in combination with the ZEOCLIP is a simple but promising closure technique for ESD-induced mucosal defects.

Miniature Manipulator Design and Cartesian Control for Minimally Invasive Transluminal Endoscopic Surgery

This paper presents a miniature manipulator under Cartesian control for minimally invasive transluminal endoscopic surgery. The manipulator had four degrees of freedom (DoFs) and a diameter of only 3.5 mm. The compact size of the manipulator allowed it to pass through the instrument channel of the endoscope, and its high dexterity allowed it to perform most of the operations in endoscopic surgery such as marking, grasping, hanging, etc. The implicit function relationship in the kinematics of the continuum manipulator was analyzed. By introducing the regression analysis method, the analytical form of the inverse kinematics was obtained. The distribution of singularities in the manipulator workspace was analyzed with emphasis. The presence of singularities made Cartesian mapping control between the primary side and secondary side impossible. By introducing the smoothing method of the joint trajectory, the discontinuity of the joint velocity at the singularity was avoided and the primary-secondary mapping under Cartesian control was realized. The trajectory-tracking experiment proved that the smoothness of the joint trajectory could make the manipulator smoothly pass through the singularity. The fixed-point marking experiment proved that the Cartesian control could improve the intuition of operation and the efficiency of task completion. Comprehensive performance experiments showed that the manipulator had enough dexterity to execute complex operations.

Endoscopic resection of upper GI extraluminal tumors (with videos)

BACKGROUND AND AIMS

Endoscopic resection is a feasible treatment for GI extraluminal tumors but remains a challenging procedure with limited data. In this study, we assessed the safety and efficacy of endoscopic resection for extraluminal tumors in the upper GI tract.

METHODS

From May 2016 to December 2021, 109 patients undergoing endoscopic resection for extraluminal tumors in the upper GI tract were retrospectively included. Clinicopathologic characteristics, procedure-related parameters, adverse events (AEs), and follow-up outcomes were analyzed.

RESULTS

The en-bloc tumor resection rate was 94.5% and en-bloc retrieval rate 86.2%. Statistical analysis revealed tumor size ≥3.0 cm and irregular shape as significant risk factors for piecemeal extraction. Resection time and suture time were 46.8 ± 33.6 minutes and 20.6 ± 20.1 minutes, respectively. Large tumor size was significantly associated with a longer procedure duration. Five patients (4.6%) experienced major AEs, including recurrent laryngeal nerve injury, hydrothorax, major bleeding, local peritonitis, duodenal leakage, and repeat endoscopic surgery for tumor extraction. Minor AEs occurred in 13 patients (11.9%). Irregular tumor shape and tumor location (duodenum) were significantly associated with AE occurrence. Mean postoperative hospital stay was 4.7 ± 3.3 days. No recurrence or metastasis was observed during the mean follow-up period of 31.8 ± 15.2 months.

CONCLUSIONS

Endoscopic resection is a safe and feasible therapeutic approach for upper GI extraluminal tumors. Tumor size, shape, and location impact the difficulty and safety of the procedure. Endoscopic resection of duodenal tumors is also feasible but associated with an increased risk of AEs compared with tumors in other locations.

A novel endoscopic purse-string suture technique, "loop 9", for gastrointestinal defect closure: a pilot study

BACKGROUND : This study aimed to assess the feasibility and efficacy of the novel loop 9 method of gastrointestinal (GI) defect closure. METHODS : 20 patients underwent a GI procedure that required defect closure. Loop 9 can be delivered through a single instrument channel (3.2 mm) and released at the defect site. After it has been anchored by two clips positioned on opposite sides of the defect edge, the loop 9 is tightened by pulling the end of the suture intraluminally using biopsy forceps. Additional clips are placed to achieve complete closure. The primary outcome was complete closure rate. The secondary outcomes were closure time, sustained closure rate, and adverse events. RESULTS : Complete closure was achieved in 100 % of cases. The mean size of the mucosal defects was 17.5 mm (range 10-55 mm). The median closure time was 14 minutes. The sustained closure rate was 90 %. No adverse events were noted. CONCLUSIONS : The loop 9 technique is feasible and effective in achieving complete and sustained closure of therapeutic endoscopy-related GI defects.

Endoscopic hand suturing for mucosal defect closure after gastric endoscopic submucosal dissection may reduce the risk of postoperative bleeding in patients receiving antithrombotic therapy

OBJECTIVES

Endoscopic hand suturing (EHS) is expected to decrease the risk of post-endoscopic submucosal dissection (ESD) bleeding by closing mucosal defects. We investigated the efficacy of EHS after gastric ESD in patients with antithrombotic agents.

METHODS

In this prospective single-arm trial, patients taking antithrombotic agents for cardiovascular disease, arrhythmia, cerebrovascular disease and/or peripheral arterial disease and having <3-cm gastric neoplasms were recruited. The mucosal defects after ESD were closed by EHS in which the needle was delivered through an overtube, and the mucosal rim of the defect was continuously sutured in a linear fashion by manipulating the needle grasped with the needle holder, followed by cutting the remnant suture and retrieval of the needle. The primary endpoint was the incidence of postoperative bleeding within 4 weeks after ESD.

RESULTS

Twenty-two lesions in 20 patients (continuing antiplatelet agents in 11, anticoagulant agents in eight, both in one) underwent ESD followed by EHS. All defects (median size, 30 mm; range, 12-51 mm) were completely closed by EHS and remained closed on postoperative day 3. The median number of stitches was six (range, 4-8) and median suturing time was 36 (range, 24-60) min. There were no adverse events during/after EHS or postoperative bleeding.

CONCLUSIONS

Postoperative bleeding was not observed in patients taking antithrombotic agents without perioperative cessation. EHS appears to be useful for prevention of post-gastric ESD bleeding in high-risk patients. (Clinical registration number: UMIN000024184).

Closure techniques in exposed endoscopic full-thickness resection: Overview and future perspectives in the endoscopic suturing era

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.

Endoscopic Treatment for Superficial Nonampullary Duodenal Tumors

Superficial nonampullary duodenal epithelial tumors are considered rare but have been increasingly recognized in recent years. Accordingly, the importance of endoscopic treatment for the lesions are also increasing. An endoscopic resection can be considered for duodenal adenoma and mucosal cancer. The choice of resection method should be made based on the size of the lesion, endoscopic findings, pathologic diagnosis, and risk of procedure-related complication. For small adenomas <10 mm in size, endoscopic mucosal resection (EMR), cold snare polypectomy, and underwater EMR can be considered. An en bloc or piecemeal resection using EMR or underwater EMR can be selected for 10-20 mm sized adenomas. For lesions ≥20 mm in size or suspicious for mucosal cancer, an endoscopic submucosal dissection followed by closure of the mucosal defect conducted by an experienced endoscopist is appropriate.

Hazardous repeat bleeding after colorectal endoscopic submucosal dissection in a patient with immune thrombocytopenia: complete hemostasis using an over-the-scope clip

A 76-year-old man diagnosed with early-stage colorectal cancer was referred to our hospital for endoscopic submucosal dissection (ESD). The patient had a low platelet count (31,000/µL) due to immune thrombocytopenia (ITP). The cancerous lesion was completely resected without any adverse events. A blood test performed 1 day post-ESD showed no progression of anemia and the initial postoperative course was uneventful. However, 7 days after ESD, dark red stools were observed, and we performed an emergency colonoscopy. We stopped the bleeding twice using hemoclips and hemostatic forceps. Since the patient's platelet count remained below 50,000/µL, we started thrombopoietin receptor agonist treatment with eltrombopag (12.5 mg/day) for thrombocytopenia. Although the platelet count increased, the patient experienced rebleeding for the fourth time and underwent an emergency colonoscopy, during which we used an over-the-scope clip (OTSC) to achieve hemostasis. No rebleeding occurred after OTSC intervention, and the platelet count stabilized at approximately 50,000/µL. We discharged the patient on Day 34 after ESD. Although the guidelines do not specify a target platelet count for performing ESD, a platelet count < 50,000/µL should be considered low. Furthermore, an OTSC may be useful for treating intractable bleeding.

Feasibility of a new ligation using the double-loop clips technique without an adhesive agent for ulceration after endoscopic submucosal dissection of the colon (with video)

BACKGROUND AND AIMS

Several ligation techniques for ulceration after endoscopic submucosal dissection (ESD) have been reported, but none have been established for clinical use because of technical complexity and the need for expensive equipment. Therefore, the technical feasibility of a new ligation method using the double-loop clips (D-L clips) technique without an adhesive agent for ulceration after ESD of the colon was assessed.

METHODS

Among 35 patients who underwent ESD of the colon in Kushiro Rosai Hospital between April 2019 and September 2019, 26 patients who underwent ligation using the D-L clips technique for the post-ESD ulcer bed were included in this retrospective study. Continuation or cessation of antithrombotic agents was based on the Guidelines for Gastroenterological Endoscopy in Patients Undergoing Antithrombotic Treatment.

RESULTS

The rate of en bloc R0 resection was 97.1%, the median length of the resected specimen was 3.2 cm (interquartile range [IQR], 2.8-3.8 cm), and the complete ligation rate was 88.5% (23 of 26). Excluding patients with lesion sites in the rectum below the peritoneal reflection, the complete ligation rate was 95.5% (21 of 22). The median duration of the ligation procedure was 20 minutes (IQR, 16-24 minutes). The only delayed procedural adverse event was post-ESD coagulation syndrome in 1 patient. Incomplete ligation was significantly more frequent in patients with lesion sites in the inferior rectal valve/anal verge area (P = .0269).

CONCLUSIONS

Ligation using the D-L clips technique without an adhesive agent is feasible for closing ulceration after ESD of the colon, whereas other techniques may be necessary for lesions in the rectum below the peritoneal reflection.

Endoscopic suturing promotes healing of mucosal defects after gastric endoscopic submucosal dissection: endoscopic and histologic analyses in in vivo porcine models (with video)

BACKGROUND AND AIMS

Endoscopic suturing of mucosal defects after endoscopic submucosal dissection (ESD) is expected to prevent postoperative adverse events. We aimed to endoscopically and histologically evaluate the healing process of post-ESD mucosal defects closed with endoscopic hand suturing (EHS) in in vivo porcine models.

METHODS

Twelve mucosal defects (2 cm in size) were created in 2 pigs (6 defects per pig). Initially, 2 defects were created: one was closed with EHS (sutured group) and the other was kept open (control group). On postoperative days (PODs) 7 and 14, 2 additional defects were created in each session, and they were treated in the same manner as in the initial procedure. On POD 21, the entire stomach, with the 6 lesion sites, was extracted for histologic evaluation after endoscopic observation.

RESULTS

Endoscopically, all sutured sites remained closed in all sessions (PODs 7, 14, and 21). Histologically, on POD 14, the epithelium and muscularis mucosae were appropriately connected. The mucosae were covered with the epithelium without inversion of the mucosal edge in the sutured group, whereas the ulcer bed was exposed in the control group. Furthermore, the degree of neovascularity and fibroblasts in the submucosa was smaller in the sutured group than that in the control group.

CONCLUSIONS

Our findings suggest that endoscopic suturing promotes healing of post-ESD mucosal defects histologically in in vivo porcine models. Thus, endoscopic mucosal closure after ESD might be clinically useful for the prevention of delayed perforation/bleeding if secure suturing is performed endoscopically.

The Use of the Overstitch to Close Endoscopic Resection Defects

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.

Complete closure versus simple closure for perforations during colorectal endoscopic submucosal dissection

Background and study aims  The efficacy of complete closure versus simple closure for perforations during endoscopic submucosal dissection (ESD) has never been evaluated. We evaluated the efficacy of complete closure and simple closure for perforations and muscular layer injuries incurred during ESD. Patients and methods  Thirty-four consecutive patients who underwent "complete closure" or "simple closure" for correction of perforations and muscular layer injuries during colorectal ESD were enrolled in this study. Complete closure was performed by the mucosa-submucosa clip closure method using only conventional endo-clips. For simple closure, endo-clips are placed just for perforation or muscular layer injury, while leaving any mucosal defects open. Results  Among the 15 patients in the complete closure group, eight developed perforations and seven developed muscular layer injuries. Among the 19 patients in the simple closure group, six developed perforations and 13 developed muscular layer injuries during the ESD procedure. There were no statistically significant differences between the two groups in inflammatory reactions, adverse events, or length of the hospital stay. Conclusion  Complete closure and simple closure for perforations and muscular layer injuries during ESD seem to have similar efficacy. While simple closure for a perforation during ESD seems sufficient, further study will be required to confirm our results.

Closure of Defects and Management of Complications

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.

Over-the-scope clip system: A review of 1517 cases over 9 years

Rescue therapy for gastrointestinal (GI) refractory bleeding, perforation, and fistula has traditionally required surgical interventions owing to the limited performance of conventional endoscopic instruments and techniques. An innovative clipping system, the over-the-scope clip (OTSC), may play an important role in rescue therapy. This innovative device is proposed as the final option in endoscopic treatment. The device presents several advantages including having a powerful sewing force for closure of GI defects using a simple mechanism and also having an innovative feature, whereby a large defect and fistula can be sealed using accessory forceps. Consequently, it is able to provide outstanding clinical effects for rescue therapy. This review clarifies the current status and limitations of OTSC according to different indications of GI refractory disease, including refractory bleeding, perforation, fistula, and anastomotic dehiscence. An extensive literature search identified studies reported 10 or more cases in which the OTSC system was applied. A total of 1517 cases described in 30 articles between 2010 and 2018 were retrieved. The clinical success rates and complications were calculated overall and for each indication. The average clinical success rate was 78% (n = 1517) overall, 85% for bleeding (n = 559), 85% (n = 351) for perforation, 52% (n = 388) for fistula, 66% (n = 97) for anastomotic dehiscence, and 95% (n = 122) for other conditions, respectively. The overall and severe OTSC-associated complications were 1.7% (n = 23) and 0.59% (n = 9), respectively. This review concludes that the OTSC system may serve as a safe and productive device for GI refractory diseases, albeit with limited success for fistula.

Successful treatment of an esophageal perforation that occurred during endoscopic submucosal dissection for esophageal cancer using polyglycolic acid sheets and fibrin glue

A 74-year-old female, who was diagnosed with superficial esophageal cancer, underwent endoscopic submucosal dissection (ESD) at another hospital, but a perforation occurred during the procedure. The perforation was closed with endoscopic clips, and the ESD was halted. The patient was referred to our hospital, and ESD was retried. There was severe fibrosis around the lesion, and injections into the submucosal layer were difficult. In addition, it was not possible to identify the submucosal layer, and making an oral-side incision caused a large perforation along the incision line. As continuing the submucosal dissection with an endoknife was considered difficult, the lesion was finally resected with hybrid ESD using a snare. The perforation was closed using polyglycolic acid (PGA) sheets and fibrin glue. Endoscopy performed 6 days later showed that the defect had been closed, and no contrast leakage was detected. Follow-up endoscopy conducted 3 months after the ESD showed ulcer healing at the dissection site and scar formation, but no residual tumor or esophageal stricture was noted. Our experience suggests that the use of PGA sheets with fibrin glue is a feasible, safe, and effective way of treating large esophageal perforations during ESD.

Feasibility of endoscopic mucosa-submucosa clip closure method (with video)

Background and study aims We developed a new endoscopic closure technique using just conventional endoclips. The feasibility of endoscopic mucosa-submucosa clip closure method was evaluated in this clinical pilot study.

Patients and methods This study involved consecutive 25 patients who underwent colorectal endoscopic submucosal dissection. Endoclips were placed at the edge of the mucosal defect. Each arm of the endoclip gripped the mucosa and submucosa, respectively. The direction in which the endoclip grips were placed was parallel to the short axis of the defect. Several endoclips were applied in this way. As a result, the mucosal defect was significantly reduced in size. Additional clips were placed to achieve complete closure.

Results Mean size of resected specimen was 31.2 ± 11 mm. The success rate was 96 % (24/25). Mean procedure time was 9.6 ± 4.4 minutes. Mean number of endoclips was 9.3 ± 3.7. No complications were observed in any of the patients after the procedure.

Conclusion Endoscopic mucosa-submucosa clip closure method could close mucosal defect of size around 2 – 4 cm completely using just conventional endoclips, and it seems easy, simple and low cost.

Endoscopic Closure of Large Defects With a Novel Clipping Device and a 4S-Modified Roeder Slipknot

Endoscopic closure is an essential procedure in gastrointestinal (GI) surgery, but currently it is difficult to close large defects endoscopically because of the lack of an appropriate device. Previously, we developed an endoscopic clipping device that has multifiring function and is equipped with an independent clamp. The goal of this study is to provide a new closure method with this device and 4S-modified Roeder (4SMR) slipknot. The feasibility of the closure method is examined by deploying two clips during one insertion onto the 4SMR slipknot to close a 5 cm full-thickness linear defect of an ex vivo porcine stomach from the center. Mechanical strengths of clip-knot closure and the slipknot as regards to tensioning forces are also evaluated. Specifically, the mechanical strength of the 4SMR slipknot is verified by mean peak forces to failure, while the knot is tensioning by 2.5, 5, 7.5, and 10 N force (n = 20 for each group), respectively. Experimental results indicate the clip-slipknot closure can withstand a distracting force of 6.3 ± 5.6 N. Tensioning force has a great influence on the mechanical strength of slipknot, with the mean peak force (tensioning force) being 7.1± 6.5, 16.3 ± 9.3, 18.9 ± 10.4, and 24.2 ± 12.0 N, respectively. The proposed closure method can be used for large defects. Tensioning force higher than 5 N is suitable to ensure a stronger 4SMR slipknot.

Endoscopic full-thickness resection for gastrointestinal submucosal tumors

Endoscopic full-thickness resection (EFTR) is a "changing-concept" endoscopic resection technique, which safely allows resecting deep submucosal tumors (SMTs) in the gastrointestinal (GI) wall. It's a highly promising endoscopic procedure that allows full-thickness excision of a small piece of the complete GI wall by using only a flexible endoscope. EFTR is a meeting point between surgery and endoscopy and probably the onset of many prospective combined minimally invasive therapeutic techniques that science will explore. In this review, use of the EFTR technique for gastrointestinal SMTs is highlighted, focusing on some technical aspects, indications, contraindications and outcomes.

Transanal Minimally Invasive Anal Canal Polyp Resection

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are operative endoscopies that have been performed since a long time. Recently, an evolution of laparoscopy called transanal minimally invasive surgery began to be popularized, and it can be adopted in the face of difficult cases for EMR/ESD. In this video, a 36-year-old woman was submitted to transanal minimally invasive surgery resection, after unsuccessful ESD, for a 2-cm polyp located anteriorly in the anal canal, just beyond the pectineal line. Preoperative workup showed a uT1m versus T1sm N0 M0 lesion. The procedure was performed with a new reusable transanal platform and a monocurved coagulating hook and grasping forceps. The operative time was 90 minutes. No perioperative complications were registered, and the patient was discharged on postoperative day 1. The pathologic report showed a villotubular adenoma with high-grade dysplasia and distant-free margins. After 1 year, the patient was going well, without any recurrent disease. Transanal minimally invasive surgery resection is a good alternative to conventional endoscopic therapies, allowing a meticulous dissection under the magnified operative field's exposure, and a mucosal-submucosal flap closure under satisfactory surgeon's ergonomics.

Endoscopic resection of gastric gastrointestinal stromal tumors

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors in the gastrointestinal tract, and about 60% of them are found in the stomach. With the widespread application of endoscopy and endoscopic ultrasonography (EUS), more and more gastric GISTs are being found in an early stage (with a relative small diameter and no metastasis), giving the chance of complete resection. Endoscopic resection such as endoscopic band ligation (EBL), endoscopic submucosal dissection (ESD), endoscopic submucosal excavation (ESE), endoscopic full-thickness resection (EFTR) and submucosal tunneling endoscopic resection (STER), is a minimally invasive method compared with the conventional surgical approaches (open or laparoscopic), and has been demonstrated to be safe and effective for treating gastric GISTs. This review summarizes the recent advances on endoscopic resection of gastric GISTs, aiming to provide a rational management strategy for gastric GISTs.

Endoscopic mucosal resection and endoscopic submucosal dissection: technique and new directions

PURPOSE OF REVIEW

Most of small tumours in gastrointestinal tract are easily removed by endoscopic mucosal resection (EMR). However, EMR are sometimes not reliable to ensure the complete resection for large tumours. Although endoscopic submucosal dissection (ESD) was developed, it had a higher risk for complications such as perforation and bleeding. The techniques and clinical outcomes of EMR and ESD are reviewed.

RECENT FINDINGS

ESD is more effective for early gastric and oesophageal cancer with higher en-bloc resection rate and lower local recurrence in comparison to EMR. Several studies report favourable long-term outcomes of ESD. ESD has become a standard technique in Japan and other East Asian countries. Piecemeal resection using EMR technique is widely accepted for colorectal large adenomas and results in good clinical outcomes in most patients. However, apparent cancerous lesions need endoscopic en-bloc resection by ESD.

SUMMARY

Further development of the technique, devices and training systems will promote worldwide standardization of ESD.