Reopenable clip-over-the-line method for closing large mucosal defects following gastric endoscopic submucosal dissection: Prospective feasibility study

Reopenable clip over-the-line method in endoscopic full-thickness resection of gastric submucosal tumors: A historical control study

Objectives

Endoscopic full-thickness resection for gastric submucosal tumors is gradually gaining popularity, and secure and amenable closure is key to its success. This study aimed to compare the reopenable clip over-the-line method with the purse-string method for defect closure after endoscopic full-thickness resection for gastric submucosal tumors.

Methods

This historical control trial included 37 consecutive patients with 37 gastric submucosal tumors, who underwent endoscopic full-thickness resection between January 2021 and July 2024. All lesions were resected en bloc. After excluding three patients who underwent non-full-thickness resection, 34 patients were analyzed. Post-endoscopic full-thickness resection defects were closed using the purse-string method (n = 18) until 2022 and the reopenable clip over-the-line method (n = 16) from 2023.

Results

The median (interquartile range) time for defect closure was longer in the reopenable clip over-the-line method group of 33 (31-57) min than in the purse-string method group of 26 (24-35) min (p = 0.013). The visual analog scale pain score at the umbilical region was lower (p = 0.048) after the reopenable clip over-the-line method than after the purse-string method. In the reopenable clip over-the-line method group, post-procedural abdominal pain was confined to the epigastrium, whereas it extended to the umbilical or left lateral regions in the purse-string method group. The reopenable clip over-the-line method group commenced the diet (p = 0.001) and discharged (p = 0.024) earlier than the purse-string method group.

Conclusions

Reopenable clip over-the-line method facilitated secure post-endoscopic full-thickness resection defect closure, reduced post-procedural abdominal pain, and shortened the fasting and hospitalization periods after endoscopic full-thickness resection in gastric submucosal tumors.

Endoscopic closure using a dedicated device following gastric endoscopic submucosal dissection: Multicenter, prospective, observational pilot study

Background and study aims

Development of a simple, optimized closure method for mucosal defects left by gastric endoscopic submucosal dissection (ESD) is warranted. Herein, we developed a novel and dedicated closure device called FLEXLOOP and aimed to assess feasibility and safety of the closure using FLEXLOOP following gastric ESD.

Patients and methods

This multicenter, prospective, observational study enrolled patients clinically diagnosed with gastric neoplasms < 30 mm in size. Following gastric ESD, closure of the mucosal defect was performed using a FLEXLOOP with standard clips. The primary outcome was the complete closure rate. The secondary outcomes were procedure time, number of clips, sustained closure rate on second-look endoscopy on postoperative days (PODs) 5 to 7, and rate of post-ESD bleeding.

Results

Overall, 35 patients were included in this study. The median specimen size was 32 mm. The mucosal defect was completely closed in 31 patients (89%; 95% confidence interval, 73%-99%) and incompletely closed in four patients (11%). Median closure time was 11 minutes and median number of clips was 10. Second-look endoscopy performed on PODs 5 to 7 demonstrated sustained, partially sustained, and unsustained closures in seven (20%), 22 (63%), and six patients (17%), respectively. Post-ESD bleeding and complications related to FLEXLOOP were not observed.

Conclusions

Closure using FLEXLOOP is feasible and safe. Our technique using this new device can be an attractive option for more easily closing mucosal defects. However, further clinical research is warranted to confirm that this technique can prevent delayed complications.

Advances in Endoscopic Resection

This article provides an overview of recent advances in endoscopic resection techniques. It includes the brief overview of endoscopic submucosal dissection, regional differences in ESD indications, innovation of ESD techniques, and expansion to full-thickness resection. The article covers cold snare polypectomy for small polyps with tips, underwater endoscopic mucosal resection (U-EMR) for sessile lesions with tips and expanding role of U-EMR, and the key assistive techniques for ESD that have improved the safety and efficacy. Furthermore, it discusses the emerging field of endoscopic full-thickness resection including device-assisted and freehand exposure techniques.

Closure methods for large defects after gastrointestinal endoscopic submucosal dissection

Nowadays, endoscopic submucosal dissection (ESD) is commonly performed for the removal of large gastrointestinal lesions. Endoscopic mucosal defect closure after ESD is vital to avoid adverse events. In recent years, many innovative instruments have emerged and proved to be beneficial. In this paper, we conducted a thorough literature review and summarized the closure methods for large-size post-ESD mucosal defects over decades. We separated these methods into five categories based on the operational principle: "side closure" method, "ring closure" method, "layered closure" method, "hand suturing closure" method, and "specially designed device closure" method. Side closure with clips assisted by instruments such as threads or loops is applicable for each segment of the gastrointestinal tract to prevent postoperative bleeding. If the defect tension is too large to close with the traditional side closure methods, zigzag closure and ring closure could be applied to gather the bilateral defect edges together and achieve continuous closure. In the stomach and rectum with a high risk of submucosal dead space between the submucosa and muscular layers, side closure methods with muscle layer grasping clip or layered closure methods could enable the involvement of the deep submucosa and muscle layers. The ring closure method and specially designed devices including over-the-scope clip, Overstitch, and X-tack could resolve perforation effectively. Individual closure method requires endoscope reinsertion or sophisticated operation, which may be limited by the deep location and the narrow lumen, respectively. Although specially designed devices are expected to offer promising prospectives, the cost-effectiveness remains to be a problem.

Closure of gastric mucosal defects using the reopenable-clip over-the-line method to decrease the risk of bleeding after endoscopic submucosal dissection: a multicenter propensity score-matched case-control study (with video)

BACKGROUND AND AIMS

Endoscopic submucosal dissection (ESD) is a minimally invasive treatment for early gastric cancer. However, post-ESD bleeding presents significant risks. Closing mucosal defects after ESD may reduce the incidence of post-ESD bleeding. Currently, no optimal closure method exists. Therefore, we invented clip-line closure using the reopenable-clip over-the-line method (ROLM) and evaluated its efficacy in preventing post-ESD bleeding.

METHODS

We retrospectively reviewed data from patients who underwent gastric ESD between January 2012 and March 2024. Patients were categorized into 2 groups: the nonclosure group (mucosal defect remained unclosed) and the ROLM group (defect was closed using ROLM). Baseline characteristics of patients, distribution of bleeding risk factors, and incidence and timing of post-ESD bleeding were compared between the groups. Propensity score matching was used to minimize potential bias.

RESULTS

After propensity score matching, 162 ESDs were performed for 168 lesions in the nonclosure group, whereas 160 ESDs were performed for 168 lesions in the ROLM group. The mean long diameter of the mucosal defects, procedure time for ROLM, and number of clips required for ROLM were 45.9 mm, 35.6 minutes, and 33.2, respectively. All mucosal defects resulting from the ESD were fully closed using ROLM. The post-ESD bleeding rate in the ROLM group was significantly lower (1.8%; 3 of 168 lesions) than in the nonclosure group (7.7%; 13 of 168 lesions; P = .02).

CONCLUSIONS

ROLM is feasible for mucosal defect closure after gastric ESD and effectively prevents post-ESD bleeding in high-risk patients, addressing a significant gap in existing methods.

Over-the-scope clip closure with dual thin grasping forceps after gastric endoscopic submucosal dissection

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Endoscopic full-thickness resection for gastric submucosal tumors: Japanese multicenter prospective study

OBJECTIVES

Early gastric cancer endoscopic resection (ER) is prominent in Japan. However, evidence regarding ER of gastric submucosal tumors (SMT) is limited. This prospective multicenter phase II study investigated the efficacy and safety of endoscopic full-thickness resection (EFTR) for gastric SMT.

METHODS

Endoscopic full-thickness resection indication for gastric SMT was 11-30 mm, histologically proven or clinically suspicious (irregular margin, increasing size, or internal heterogeneity) gastrointestinal stromal tumors (GIST), with no ulceration and intraluminal growth type. The primary end-point was the complete ER (ER0) rate, with a sample size of 42.

RESULTS

We enrolled 46 patients with 46 lesions between September 2020 and May 2023 at seven Japanese institutions. The mean ± SD (range) endoscopic tumor size was 18.8 ± 4.5 (11-28) mm. The tumor resection and defect closure times were 54 ± 26 (22-125) min and 33 ± 28 (12-186) min, respectively. A 100% ER0 was achieved in all 46 patients. The EFTR procedure was accomplished in all patients without surgical intervention. One patient had delayed perforation and was managed endoscopically. GIST accounted for 76% (n = 35) of the cases. R0, R1, and RX rates were 33 (77%), 3 (6.5%), and 7 (15%), respectively.

CONCLUSION

Endoscopic full-thickness resection for gastric SMT of 11-30 mm is efficacious. It warrants further validation in a large-scale cohort study to determine the long-term outcome of this treatment for patients with gastric GIST.

A novel twin-grasper assisted mucosal inverted closure technique for closing large artificial gastric mucosal defects

BACKGROUND

Large artificial gastric mucosal defects are always left unclosed for natural healing due to technique difficulties in closure. This study aims to evaluate the feasibility and safety of a new Twin-grasper Assisted Mucosal Inverted Closure (TAMIC) technique in closing large artificial gastric mucosal defects.

METHODS

Endoscopic submucosal dissection (ESD) was performed in fifteen pigs to create large gastric mucosal defects. The mucosal defects were then either left unclosed or closed with metallic clips using TAMIC technique. Successful closure rate and the wound outcomes were assessed.

RESULTS

Two mucosal defects with size of about 4.0 cm were left unclosed and healed two months after surgery. Thirteen large gastric mucosal defects were created by ESD with a medium size of 5.9 cm and were successfully closed with the TAMIC technique (100%), even in a mucosal defect with a width up to 8.5 cm. The mean closure time was 59.0 min. Wounds in eight stomachs remained completely closed 1 week after surgery (61.5%), while closure in the other five stomachs had partial wound dehiscence (38.5%). Four weeks later, all the closed defects healed well and 61.5% of the wounds still remained completely closed during healing. There was no delayed perforation or bleeding after surgery. In addition, there was less granulation in the submucosal layer of the closed wound sites than those under natural healing.

CONCLUSIONS

The present study suggests that TAMIC is feasible and safe in closing large artificial gastric mucosal defects and could improve mucosal recovery compared to natural healing process.

Twin-grasper assisted mucosal inverted closure achieves complete healing of large perforations after gastric endoscopic full-thickness resection

OBJECTIVES

This study aimed to demonstrate the feasibility and safety of a novel twin-grasper assisted mucosal inverted closure (TAMIC) technique for large perforations after gastric endoscopic full-thickness resection (EFTR) in a porcine model.

METHODS

Iatrogenic large perforations of the stomach were created and closed by an experienced endoscopist using the TAMIC technique in 12 pigs. Repeat gastroscopy was performed in 4 weeks after surgery to examine the wound sites and then the animals were killed. The primary outcomes were the successful TAMIC closure rate and the complete healing rate. Secondary end points included procedure time of TAMIC, complete inverted healing rate, delayed bleeding rate, and postsurgery perforation. Histologies of the wounds were analyzed by hematoxylin-eosin, Masson trichrome, and immunohistochemistry staining.

RESULTS

The median size of the defects was 3.5 (range 2.5-4.5) cm. TAMIC was successfully performed in all the 12 pigs. Complete healing was achieved in 11 pigs 4 weeks after operation as one pig died postsurgery due to severe pneumonia. The median procedure time for TAMIC was 39 (range 23-81) min. The complete inverted healing rate was 45.5% (5/11). No delayed bleeding or postsurgery perforation was observed. Histologic analyses showed that both the epithelium and muscularis mucosae layers were appropriately connected under inverted healing.

CONCLUSIONS

Twin-grasper assisted mucosal inverted closure is feasible and safe for closure of large perforations after gastric EFTR and could be a propagable and promising technique for clinical practice.

Reopenable clip-over-the-line method for closing large mucosal defects following colorectal endoscopic submucosal dissection: A feasibility study

Background and study aims Complete closure of large defects after colorectal endoscopic submucosal dissection (ESD) can be problematic, especially in challenging areas or lesions larger than half the lumen circumference. We report a reopenable clip-over-the-line method for such defects and aim to investigate its feasibility through a case series. Patients and methods We retrospectively evaluated data from 30 consecutive patients who underwent ESD with defect closure using the reopenable clip-over-the-line method between October 2020 and September 2022. This method requires the first clip-with-line grasp of the oral side's defect edge and muscle layer. The next reopenable clip (with a line fed through a hole in the reopenable clip tooth) is placed on the opposing mucosal defect edge and muscle layer. This process is repeated until complete closure. The primary study outcome was the rate of complete mucosal defect closure. We also reported post-procedure bleeding or perforation. Results The median dimensions of the resected specimens were 45 mm (range, 35-70) by 39 mm (range, 29-60). Complete closure was achieved for all defects, including nine rectal defects, of which three bordered the anal verge. Of the 30 defects included in this study, nine were larger than half the lumen circumference. The median closure time was 25 minutes (range, 14-52), and the median clip number was 17 (range, 9-42). No post-procedure bleeding or perforation occurred. Conclusions The reopenable clip-over-the-line method is a feasible technique for the complete closure of large colorectal defects after endoscopic submucosal dissection, regardless of location.