Current applications of endoscopic suturing

Endoscopic Treatment for Gastric Subepithelial Tumor

Most gastric subepithelial tumors (SETs) are asymptomatic and are often incidentally discovered during endoscopic procedures conducted for unrelated reasons. Although surveillance is sufficient for the majority of gastric SETs, certain cases necessitate proactive management. Laparoscopic wedge resection, although a viable treatment option, has its limitations, particularly in cases where SETs (especially those with intraluminal growth) are not visualized on the peritoneal side. Recent advances in endoscopic instruments and technology have paved the way for the feasibility of endoscopic resection of SETs. Several promising endoscopic techniques have emerged for gastric SET resection, including submucosal tunneling endoscopic resection, endoscopic full-thickness resection (EFTR), laparoscopic and endoscopic cooperative surgery (LECS), and non-exposure EFTR (non-exposed endoscopic wall-inversion surgery and non-exposure simple suturing EFTR). This study aimed to discuss the indications, methods, and outcomes of endoscopic therapy for gastric SETs. In addition, a simplified diagram of the category of SETs according to the therapeutic indications and an algorithm for the endoscopic management of SET is suggested.

Gastroesophageal reflux management after vertical sleeve gastrectomy

VSG is the most used surgical procedure in the world. Among the main complications linked to this procedure is GERD. It is apparent that endoscopic control protocols should be undertaken in all patients recovering from a VSG procedure. This is particularly key when taking into account the large number of patients suffering from GERD that show no symptoms, a situation that in many cases leads to severe esophagitis or even adenocarcinoma. Once the pertinent diagnostic tests have been carried out, the specialist should seek a conservative medical treatment including PPI. In the event that this treatment should fail, the next step to be considered should be a surgical procedure. In this case, the ideal procedure would be a reconversion to gastric bypass due to its low-risk and its results. There are other alternatives such as the Stretta, Linx or ARMS procedures; however, further research is necessary to prove their reliability.

Novel endoscopic management of gastroenterological anastomosis leakage by injecting gel-forming solutions: an experimental animal study

BACKGROUND

Anastomotic leakage (AL) after gastrointestinal surgery remains a challenging complication that requires surgical or non-surgical treatment. Although various therapeutic endoscopic techniques are available, no definitive interventions exist. We developed a therapeutic endoscopic submucosal injection method using novel gel-forming mixed solutions to close AL and evaluated the elasticity of the developed hydrogel. The safety and efficacy of the injection method were explored in porcine AL models.

METHODS

We developed a novel gel-forming solution, and the formed gel lasted approximately one week within the gastrointestinal wall. An indentation test evaluated the elasticity of the novel hydrogel. After the confirmation of AL on porcine anterior gastric walls, sodium alginate was endoscopically injected into the submucosal layer around the leakage site circularly, followed by a calcium lactate/chitosan-based solution. After that, the outcomes data were collected, and histopathological effectiveness was evaluated.

RESULTS

The increased sodium alginate elasticity with the addition of calcium lactate/chitosan-based solution facilitated long-lasting gel formation. Four pigs with AL underwent this intervention consecutively. Each endoscopic injection was completed in less than 5 min. No significant complications were observed for 3 weeks after the intervention. All AL sites were macroscopically healed. Histopathologic findings at 3 weeks showed that the wall defect was filled with collagen fibers that had grown around the site of the muscle layer tear. No tissue necrosis was observed.

CONCLUSION

This preclinical study demonstrated that the therapeutic injection method for gastroenterological AL using gel-forming solutions could be an alternative endoscopic treatment, especially in patients with severe conditions or comorbidities. The optimal target of this treatment is small size and early AL without poor blood flow or intense hypertrophic scar lesions.

Safety and efficacy of a novel suturing device for closure of large defects after endoscopic submucosal dissection (with video)

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.).

Endoscopic tissue approximation in clinical practice and the OverStitch device: a narrative review

Objective

The current article describes modern endoscopic technologies that allow for advanced endoscopic tissue approximation and suturing. These technologies include such devices as through the scope and over the scope clips, endoscopic suturing OverStitch device and through the scope suturing X-Tack device.

Background

Since the original introduction of the diagnostic endoscopy, progress in the field has been astonishing. Over the past several decades endoscopy has made numerous advancements allowing for a minimally invasive mechanism to treat life threatening conditions such as gastrointestinal (GI) bleeding, full thickness injuries, as well as chronic medical conditions such as morbid obesity and achalasia.

Methods

A narrative review of all relevant and available literature on endoscopic tissue approximation devices over the last 15 years ago was conducted.

Conclusions

Multiple new devices, including endoscopic clips and endoscopic suturing devices, have been developed for endoscopic tissue approximation that allow advanced endoscopic management of a wide variety of GI tract conditions. It is critical for practicing surgeons to actively participate in the development and use of these new technologies and devices in order to maintain leadership in the field, hone expertise, and to drive innovation. Further research in minimally invasive applications for these devices is needed as they continue to be refined. This article provides a general overview of the devices available and their clinical applications.

Duodenal stenting as a palliative approach to a malignant duodenocolonic fistula

Video 1Duodenocolonic stenting video.

Analysis of Reported Adverse Events Associated with Over-the-Scope Endoscopic Suturing System: an FDA MAUDE Database Study

PURPOSE

The over-the-scope endoscopic suturing system (ESS) (OverStitch™) is one of the most widely utilized endoscopic suturing systems in current clinical practice; however, data on the adverse events associated with this device is scarce. Our study aims to evaluate the adverse events and complications associated with the over-the-scope ESS using the FDA's Manufacturer and User Facility Device Experience (MAUDE) database.

MATERIALS AND METHODS

We analyzed the post-marketing surveillance data from the FDA MAUDE database for the over-the-scope ESS from January 2008 through June 2022.

RESULTS

Eighty-three reports were filed from January 2008 to June 2022. Adverse events were classified as device-related complications and patient-related adverse events. Seventy-seven device-related issues and 87 patient adverse events were identified. The most common device-related issue was difficulty to remove after deployment (n=12, 15.58%) followed by mechanical problem (n=10, 12.99%), mechanical jam (n=9, 11.69%), or entrapment of device (n=9, 11.69%). Of the 87 patient-related adverse events, the most common was perforation (n=19; 21.84%), followed by device embedded in tissue or plaque (n=10; 11.49%), and abdominal pain (n=8; 9.20%). Of the 19 patients who experienced perforation, two required open surgical repair and one required laparoscopic surgical repair.

CONCLUSION

The overall adverse events from the over-the-scope ESS remain acceptable as evidenced by the number of reported cases since 2008. However, it is important to note that adverse event rates might increase as the use of the device increases; therefore, it is essential for endoscopists to be aware of the potential common and rare adverse events associated with the use of the over-the-scope ESS device.

Endoscopic Closure: Tools and Techniques

The rapid expansion of third space endoscopy has necessitated development of innovative endoscopic defect closure devices and techniques. This article discusses commonly used endoscopic closure devices and techniques, data on their safety and efficacy, and a description of the authors' own practice patterns.

Endoscopic resection for gastric submucosal tumors: Japanese multicenter retrospective study

OBJECTIVES

Limited information is available on the efficacy and safety of endoscopic resection (ER) of gastric submucosal tumors (SMTs) in Japanese endoscopic practice where ER for gastric tumors is extremely popular.

METHODS

We conducted this study to elucidate the current scenario of ER for gastric SMTs in Japanese endoscopic practice. Patients (from 12 institutions) with gastric SMTs who underwent ER were enrolled from the first case until August 2020.

RESULTS

We enrolled 117 patients with 118 lesions. The number of patients who underwent ER increased over the years. The mean endoscopic tumor size was 20 ± 7.2 (8-40) mm. The growth type was primarily intraluminal (90%). The mean resection and wound closure times were 58 ± 38 (range, 12-254) min and 31 ± 41 (range, 3-330) min, respectively. Complete ER was achieved for 117 (99%) lesions. Full-thickness resection rate was 44%; however, only 12 (10%) patients required abdominal paracentesis for decompression. Endoscopic treatments were completed in 115 (97%) lesions, while three lesions required conversions to laparoscopic surgery due to luminal collapse, uncontrolled bleeding, and difficulty in defect closure. Gastrointestinal stromal tumors were the most common pathology (74%). No recurrence was observed during the mean follow-up period of 4.3 ± 2.9 years. The 5-year overall survival rate was 98.9% (95% confidence interval 97.8-100%).

CONCLUSION

Performance of ER for gastric SMTs is increasing in Japan. The technique seems feasible in Japanese endoscopic practice, warranting further validation in a prospective study.

Endoscopic suturing for GI applications: initial results from a prospective multicenter European registry

BACKGROUND AND AIMS

OverStitch devices (OverStitch and OverStitch Sx; Apollo Endosurgery, Inc, Austin, Tex, USA) are used for a wide range of applications. A European registry was created to prospectively collect technical and clinical data regarding both systems to provide procedural outcomes and to find correlation between procedural characteristics and outcomes. This study shows the initial results of the first 3 years of the registry.

METHODS

Patients who underwent endoscopic suturing from January 2018 to January 2021 at 9 centers were enrolled. Data regarding the disease treated,suturing pattern and outcomes were registered. Technical feasibility (success reaching the target area), technical success (success placing sutures), and clinical success (complete resolution of the clinical issue) were recorded and analyzed.

RESULTS

During the study period, 137 patients (57.7% men) were enrolled with 100% technical feasibility rate. Endoscopic suturing was successfully performed in 136 cases (16.7% with OverStitch Sx), obtaining a technical success rate of 99.3%. No adverse events were recorded. Overall clinical success was 89%. Mucosal defects were sutured in 32 patients (100% clinical success). Leaks/fistulas were treated in 23 patients (64.7% clinical success). The clinical success of stent fixations (n = 38) was 85%. Perforations (n = 22) were repaired with a clinical success of 94.7%. No significant correlation between location, suture pattern or number, and the success was found, except in case of fistulas where fistulas <1 cm treated by a continuous suture were more likely to achieve clinical success in the follow-up (P < .001).

CONCLUSIONS

OverStitch-based suturing is technically feasible regardless of site and method of suturing, with no cases of failure. The overall technical success rate of 99.3% and the clinical outcome success rate of 89% demonstrate that OverStitch technology provides reliable suturing with clinical advantages, especially with fistulas <1 cm.

Robotics in therapeutic endoscopy (with video)

Since its inception, endoscopy has evolved from a solely diagnostic procedure to an expanding therapeutic field within gastroenterology. The incorporation of robotics in gastroenterology initially addressed shortcomings of flexible endoscopes in natural orifice transluminal endoscopy. Developing therapeutic endoscopic robotic platforms now offer operators improved ergonomics, visualization, dexterity, precision, and control and the possibility of increasing proficiency and standardization of complex endoscopic procedures including endoscopic submucosal dissection, endoscopic full-thickness resection, and endoscopic suturing. The following review discusses the history, potential applications, and tools currently available and in development for robotics in therapeutic endoscopy.

Innovations in GI-endoscopy

Gastrointestinal endoscopy covers both diagnosis and therapy. Due to its diagnostic accuracy and minimal invasiveness, several innovations have been made within the last years including artificial intelligence and endoscopic tumor resection. The present review highlights some of these innovation. In addition, a special focus is set on the experience made by our own research group trying to combine the expertise of endoscopists/ physicians as well as engineers and computer scientists.

Randomized experimental study of two novel techniques for transanal repair of dehiscent low rectal anastomosis

BACKGROUND

Anastomotic leak after low anterior rectal resection is a dreadful complication. Early diagnosis, prompt management of sepsis followed by closure of anastomotic defect may increase chances of anastomotic salvage. In this randomized experimental study, we evaluated two different methods of trans-anal anastomotic repair.

METHODS

A model of anastomotic leak was created in 42 male pigs. Laparoscopic low anterior resection was performed with anastomosis created using a circular stapler with half of the staples removed. Two days later, animals were randomized into a TAMIS (trans-anal minimally invasive surgery) repair, endoscopic suture (ENDO) or control group with no treatment (CONTROL). Signs of intraabdominal infection (IAI), macroscopic anastomotic healing and burst tests were evaluated to assess closure quality after animals were sacrificed on the ninth postoperative day.

RESULTS

Closure was technically feasible in all 28 animals. Two animals had to be euthanized due to progressive sepsis at four and five days after endoscopic closure. Healed anastomosis with no visible defect was observed in 10/14 and 11/14 animals in TAMIS and ENDO groups, respectively, versus 2/14 in CONTROL (p < 0.05). Overall IAI rate was significantly lower in TAMIS (4/14; p = 0.006) and ENDO (5/14; p = 0.018) compared to CONTROL (12/14). Burst tests confirmed sealed closure in healed anastomosis with a median failure pressure of 190 (110-300) mmHg in TAMIS and 200 (100-300) mmHg in ENDO group (p = 0.644).

CONCLUSION

In this randomized experimental study, we found that both evaluated techniques are effective in early repair of dehiscent colorectal anastomosis with a high healing rate.

POEM, GPOEM, and ZPOEM

Our tripartite narrative review discusses Peroral Endoscopic Myotomy (POEM), gastric POEM (GPOEM) and POEM for Zenker's diverticula (ZPOEM). POEM is the prototypical procedure that launched the novel "3rd space endoscopy" field of advanced endoscopy. It revolutionized achalasia therapy by offering a much less invasive version of the prior gold standard, the laparoscopic Heller myotomy (HM). We review in detail indications, outcomes, technique variations and comparative data between POEM and HM particularly with regard to the hotly debated issue of GERD. We then proceed to discuss two less illustrious but nevertheless important offshoots of the iconic POEM procedure: GPOEM for gastroparesis and ZPOEM for the treatment of hypopharyngeal diverticula. For GPOEM, we discuss the rationale of pylorus-directed therapies, briefly touch on GPOEM technique variations and then focus on the importance of proper patient selection and emerging data in this area. On the third and final part of our review, we discuss ZPOEM and expound on technique variations including our "ultra-short tunnel technique". Our review emphasizes that, despite the superiority of endoscopy over surgery for the treatment of hypopharyngeal diverticula, there is no clear evidence yet of the superiority of the newfangled ZPOEM technique compared to the conventional endoscopic myotomy technique practiced for over two decades prior to the advent of ZPOEM.

Advances in endoscopic resection: a review of endoscopic submucosal dissection (ESD), endoscopic full thickness resection (EFTR) and submucosal tunneling endoscopic resection (STER)

Subepithelial lesions are often detected incidentally in patients undergoing an endoscopy. They are common tumors of the gastrointestinal (GI) tract which can originate from different layers of the GI tract wall. These lesions can be further classified based on GI layer of origin and unique histochemical staining. While most are benign and asymptomatic, some of these lesions have malignant potential with distant metastases. However, current diagnostic modalities including endoscopy with biopsy or endoscopic ultrasound with fine needle aspiration are not always reliable. In addition, management of these lesions has historically involved surgical resection via open or laparoscopic approaches. In recent years, with advancement in endoscopic techniques and improvement in endoscopists' skills, less invasive procedures such as endoscopic submucosal dissection (ESD), endoscopic full thickness resection (EFTR) and submucosal tunneling endoscopic resection (STER) have been developed and now are being used by endoscopists worldwide. Upon reviewing the literature, multiple studies have shown the advantages of these endoscopic techniques when compared with surgical treatment. As a result, there has been a dramatic shift towards minimally invasive endoscopic procedures for the management of these subepithelial lesions. In this review article, we will discuss these endoscopic resection techniques in detail, their safety and efficacy, as well as comparison studies to other therapeutic modalities.

OverStitch Sx Endoscopic suturing system in minimally invasive endoscopic procedures: overview of its safety and efficacy and comparison to oversticthTM

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.

The efficacy and long-term outcomes of endoscopic full-thickness suturing for chronic gastrointestinal fistulas with an Overstitch device: is it a durable closure?

BACKGROUND AND AIM

Endoscopic closure of chronic gastrointestinal fistulas (CGFs) is challenging due to their epithelialized surfaces. The aim of this study was to assess the efficacy and long-term closure rate of endosuturing for CGFs with an Apollo Overstitch device.

PATIENTS AND METHODS

Consecutive CGF patients undergoing endosuturing for fistula closure from April 2018 to January 2020 at the First Affiliated Hospital of Nanjing Medical University were enrolled for retrospective review. Demographics, fistula characteristics, details of the suturing procedures and outcomes were collected for analysis.

RESULTS

Twenty patients (mean age 59.8 ± 9.1 years; 85% males) with a total of 23 CGFs underwent sutured fistula closure. Esophagotracheal fistulas were the most common CGFs (12/23, 52.2%), and prior cancer surgery was the most common fistulization etiology (14/20, 70%). Twelve patients (12/20, 60%) had undergone failed endoscopic attempts at fistula closure before suturing. Additional endoscopic therapies used during suturing were 100% argon plasma coagulation, 50% clip fixation, and 10% stent placement. Although all patients undergoing suturing achieved immediate technical success of fistula closure, sustained fistula closure was observed in only 5 patients (5/20, 25.0%) on surveillance endoscopy 3 months after suturing with a mean follow-up of 19.5 months. Esophagotracheal fistula patients were predisposed to shorter dehiscence-free survival than those with other fistulas (HR 3.378; 95% CI 1.127-10.13).

CONCLUSIONS

Endosuturing is safe and should be considered for use as the first-line or salvage therapy for CGF closure, primarily for patients with fistulas not involving the trachea. However, the long-term healing of CGFs by suturing is challenging, and CGF patients might not benefit from repeated suturing.

AGA Clinical Practice Update on Endoscopic Management of Perforations in Gastrointestinal Tract: Expert Review

BEST PRACTICE ADVICE 1: For all procedures, especially procedures carrying an increased risk for perforation, a thorough discussion between the endoscopist and the patient (preferably together with the patient's family) should include details of the procedural techniques and risks involved. BEST PRACTICE ADVICE 2: The area of perforation should be kept clean to prevent any spillage of gastrointestinal contents into the perforation by aspirating liquids and, if necessary, changing the patient position to bring the perforation into a non-dependent location while minimizing insufflation of carbon dioxide to avoid compartment syndrome. BEST PRACTICE ADVICE 3: Use of carbon dioxide for insufflation is encouraged for all endoscopic procedures, especially any endoscopic procedure with increased risk of perforation. If available, carbon dioxide should be used for all endoscopic procedures. BEST PRACTICE ADVICE 4: All endoscopists should be aware of the procedures that carry an increased risk for perforation such as any dilation, foreign body removal, any per oral endoscopic myotomy (Zenker's, esophageal, pyloric), stricture incision, thermal coagulation for hemostasis or tumor ablation, percutaneous endoscopic gastrostomy, ampullectomy, endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), endoluminal stenting with self-expanding metal stent (SEMS), full-thickness endoscopic resection, endoscopic retrograde cholangiopancreatography (ERCP) in surgically altered anatomy, endoscopic ultrasound (EUS)-guided biliary and pancreatic access, EUS-guided cystogastrostomy, and endoscopic gastroenterostomy using a lumen apposing metal stent (LAMS). BEST PRACTICE ADVICE 5: Urgent surgical consultation should be highly considered in all cases with perforation even when endoscopic repair is technically successful. BEST PRACTICE ADVICE 6: For all upper gastrointestinal perforations, the patient should be considered to be admitted for observation, receive intravenous fluids, be kept nothing by mouth, receive broad-spectrum antibiotics (to cover Gram-negative and anaerobic organisms), nasogastric tube (NGT) placement (albeit some exceptions), and surgical consultation. BEST PRACTICE ADVICE 7: For upper gastrointestinal tract perforations, a water-soluble upper gastrointestinal series should be considered to confirm the absence of continuing leak at the perforation site before initiating a clear liquid diet. BEST PRACTICE ADVICE 8: Endoscopic closure of esophageal perforations should be pursued when feasible, utilizing through-the-scope clips (TTSCs) or over-the-scope clips (OTSCs) for perforations <2 cm and endoscopic suturing for perforations >2 cm, reserving esophageal stenting with SEMS for cases where primary closure is not possible. BEST PRACTICE ADVICE 9: Endoscopic closure of gastric perforations should be pursued when feasible, utilizing TTSCs or OTSCs for perforations <2 cm and endoscopic suturing or combination of TTSCs and endoloop for perforations >2 cm. BEST PRACTICE ADVICE 10: For large type 1 duodenal perforations (lateral duodenal wall tear >3 cm), being cognizant of the difficulty in closing them endoscopically, urgent surgical consultation should be made while the feasibility of endoscopic closure is assessed. BEST PRACTICE ADVICE 11: Because type 2 periampullary (retroperitoneal) perforations are subtle and can be easily missed, the endoscopist should carefully assess the gas pattern on fluoroscopy to avoid delays in treatment and request a computed tomography scan if there is a concern for such a perforation; identified perforations of this type at the time of ERCP may be closed with TTSCs if feasible and/or by placing a fully covered SEMS into the bile duct across the ampulla. BEST PRACTICE ADVICE 12: For the management of large duodenal polyps, endoscopic mucosal resection (EMR) should only be performed by experienced endoscopists and endoscopic submucosal dissection (ESD) only by experts because both EMR and ESD in the duodenum require proficiency in resection and mucosal defect closure techniques to manage immediate and/or delayed perforations (caused by the proteolytic enzymes of the pancreas). BEST PRACTICE ADVICE 13: Endoscopists should be aware that colon perforations occurring during diagnostic colonoscopy are most commonly located in the sigmoid colon due to direct trauma from forceful advancement of the colonoscope. Such tears recognized at the time of colonoscopy may be closed by TTSCs or OTSCs if the bowel preparation is good and the patient is stable. BEST PRACTICE ADVICE 14: Although colon perforation is responsive to various endoscopic tools such as TTSC, OTSC, and endoscopic suturing, perforations in the right colon, especially in the cecum, have been relegated to using only TTSCs because of inability to reach the site of the perforation with an endoscopic suturing device or OTSC if the colon is tortuous or unclean. Recently a new suture-based device for defect closure has been introduced allowing deep submucosal and intramuscular enhanced fixation through a standard gastroscope or colonoscope. BEST PRACTICE ADVICE 15: Patients with perforations who are hemodynamically unstable or who have suffered a delayed perforation with peritoneal signs or frank peritonitis should be surgically managed without any attempt at endoscopic closure. BEST PRACTICE ADVICE 16: In any adverse event including perforation, it is paramount to ensure accurate documentation, prompt discussion with the patient and family, and swift reporting to the quality officer (or equivalent) and risk management team of the institution (in major adverse events).

Assessment and management of gastroesophageal reflux disease following bariatric surgery

Gastroesophageal reflux disease (GERD) is a common disease in patients with obesity. The incidence of de novo GERD and the effect of bariatric surgery on patients with pre-existing GERD remain controversial. Management of GERD following bariatric surgery is complicated and can range from medical therapy to non-invasive endoscopic options to invasive surgical options. To address these issues, we performed a systematic review of the literature on the incidence of GERD and the various modalities of managing GERD in patients following bariatric surgery. Given the increased number of laparoscopic sleeve gastrectomy (LSG) procedures being performed and the high incidence of GERD following LSG, bariatric surgeons should be familiar with the options available to manage GERD following LSG as well as other bariatric procedures.

Colorectal Endoscopic Submucosal Dissection: An Update on Best Practice

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.

The addition of flexible endoscopic suturing to stenting for the management of transmural esophageal wall defects: a single tertiary center experience

BACKGROUND AND AIMS

Endoscopic stenting is the standard of care for full thickness esophageal wall defects. The aim of this study is to evaluate outcomes of endoscopic closure of esophageal defects using stenting, with or without endoscopic suturing.

METHODS

This is a single-center retrospective study of patients with esophageal wall defects who underwent endoscopic interventions. Outcomes of stenting with or without endoscopic suturing of the defect were assessed. Univariate and multivariate logistic regression models were used to examine factors associated with successful defect closure.

RESULTS

One hundred and fourteen patients with esophageal wall defects underwent 254 endoscopies with an overall complete closure rate of 75.8%. Twenty-three (20.2%) patients underwent primary closure using endoscopic suturing and subsequent esophageal stenting, while 91 (79.8%) underwent esophageal stenting only. The dual modality group (versus the stent-only group) had similar defect closure rates (84.2 vs. 73.8%, p = 0.55) and time to stent migration (37 vs. 12.5 days, p = 0.07), but was associated with longer procedure times (60 vs. 36 min, p < 0.01) and fewer additional endoscopic procedures (13.6 vs. 43.2%, p = 0.01). Stent suturing significantly decreased migration (35.5 vs. 58.5%, p = 0.04), was associated with fewer additional endoscopies (15.4 vs. 50%, p < 0.01) and reduced need for additional stents (7.7 vs. 34.3%, p < 0.01). On multivariate analysis, chronic defects (> four weeks old) were 81% less likely to close compared to acute (≤ 4 weeks) defects (OR 0.19, CI 0.04-0.77, p = 0.02), and large diameter stents (23 mm) were associated with higher odds of defect closure (OR 3.36, CI 1.02-11.4, p = 0.04).

CONCLUSION

Endoscopic treatment of esophageal wall defects is safe, effective, and more likely to be successful in acute defects using larger caliber stents. Stent suturing reduces migration, need for additional endoscopic procedures, and stent exchanges. Further comparative studies with larger cohorts are needed to validate our results.

Suturing methods in prolapse surgery: a biomechanical analysis

INTRODUCTION

Pelvic organ prolapse is a common problem in urogynecological surgery. Abdominal and laparoscopic sacrocolpopexy is currently considered to be the gold standard of treatment. The main problem remains the anatomical point of fixation as well as how sutures are placed. We evaluated the biomechanical difference between an in-line ligament suture versus an orthogonal ligament suture and a single suture versus a continuous suture at the anterior longitudinal ligament in an in-vitro, sacrocolpopexy model.

METHODS

Biomechanical in-vitro testing was performed on human, non-embalmed, female cadaver pelvises. An Instron test frame (tensinometer) was used for load/ displacement analysis. The average patient age was 75 years. Ligament preparation yielded 15 ligaments available for testing. Recorded parameters were the ultimate load, failure displacement, and stiffness.

RESULTS

This in-vitro analysis of different suturing methods showed the difference between an orthogonal and an in-line approach to be the ultimate load. Orthogonal sutures displayed an ultimate load of 80 N while in-line suturing yielded only 57 N (p < 0.05). For the anterior longitudinal ligament, this study demonstrated that continuous suture is significantly superior to a single suture regarding failure displacement (p < 0.05).

CONCLUSION

We established baseline biomechanical parameters for the sacrospinous ligament and anterior longitudinal ligament. An orthogonal suture is superior to an in-line suture in an in-vitro model. A continuous suture is superior to a single suture at the anterior longitudinal ligament. Clinical trials might be able to evaluate whether any clinical significance can be established from these findings.

Gastrointestinal exposed endoscopic full-thickness resection in the era of endoscopic suturing: a retrospective single-center case series

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.

The Off-Label Use of a Lumen-Apposing Metal Stent (LAMS) for a Benign Colon Anastomotic Stricture Causing Recurrent Bowel Obstruction in a Patient with Keloids

Anastomotic strictures are a known complication of colorectal surgery. Despite a wide range of medical devices that have been deployed for this complication, outcomes remain challenging. Lumen-apposing metal stents (LAMSs) have recently emerged as a potentially superior therapeutic option. We herein report a patient with a past medical history of pT3, N0 adenocarcinoma of the colon with anastomotic stricture recurrence who underwent successful placement of an LAMS. We suggest that patients with a predisposition for keloid formation or fibrosis-prone anastomotic wound healing should be considered for LAMS deployment early in the treatment course.

Comparison of Endoscopic Submucosal Dissection Application on Mucosal Tumor and Subepithelial Tumor in stomach

Background: Endoscopic submucosal dissection is minimal invasive endoscopic procedure to deal with gastric tumor. Initially, it was developed to resect mucosal neoplasm since 2000 and extended its application to submucosal tumor in the following years. Although the basic ESD skills are similar in gastric mucosal tumor and subepithelial tumor, the success rate, complication may be different between the two types of gastric tumor resection. This retrospective study is conducted to analyze the ESD procedure in gastric mucosal tumor and subepithelial tumor.

Methods: From 2007 to 2016, we reviewed all patients who underwent endoscopic submucosal dissection for gastric mucosal tumor and subepithelial tumor in Kaohsiung Medical University Hospital.

Results: Totally, 35 patients with gastric subepithelial tumor and 41 patients with gastric mucosal tumor received endoscopic submucosal dissection are enrolled. Among 35 patients with subepithelial tumor, 32 (91.4%) patients achieved curative treatment. 1 patient received emergent operation and 2 patients received salvage operation to complete tumor resection. 8 patients (22.9%) occurred perforation and no delay bleeding was found. Among 41 patients with mucosal neoplasm, 30 (71.4%) patients achieved curative treatment. 2 patients received emergent operation and 9 patients received salvage operation to complete tumor resection. 9 patients (21.9%) occurred complication, 6 patients occurred delay bleeding and 3 patients had perforation.

Conclusions: Comparing ESD between gastric mucosal tumor and subepithelial tumor, ESD had similar efficiency in curative treatment. However, ESD in subepethelial tumor encountered higher perforation and lesser delay bleeding.

The Usefulness of an Endoscopic OverStitch Suturing System for Managing Anastomotic Dehiscence - A Case Report

Anastomotic dehiscence (AD) after colorectal surgery contributes to poor outcomes resulting in multiple postoperative complications. Conventional management would be a repeat laparotomy and tension suturing. But owing to the unhealthy vicinities near the suture lines, there is a significant risk of technical failure which further increases postoperative morbidity and mortality. A 60-year-old male, with a history of hypertension, ischemic heart disease, and previous percutaneous transluminal coronary angioplasty, underwent sigmoid colectomy with colorectal anastomosis for complicated sigmoid diverticulitis. He then developed anastomotic site leak for which an ileostomy was done. Prior to the ileostomy revision, he was referred for colonoscopic evaluation which showed the persistence of a partial AD. We decided to close the defect endoscopically with the Apollo OverStitch device. Initial tissue preparation was done by creating a surgical surface using argon plasma coagulation at the perimeter of the leak site. A double channel therapeutic endoscope with the OverStitch assembly was passed to take full-thickness running sutures across the rent to facilitate full closure. The area examined showed good suture approximation and complete closure. The procedure was successful with no immediate or delayed postprocedural complications. Repeat endoscopic evaluation at about two weeks showed well-approximated edges with intact suture lines, and there was complete resolution of the leak. The patient subsequently underwent revision surgery after a month. The patient is under close follow-up and doing well. The Apollo OverStitch device has certainly opened new avenues in flexible endoscopic surgery which need further exploratory studies to add to existing promising results.

Life on a knife edge: the optimal approach to the management of perforations during endoscopic submucosal dissection (ESD)

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.

Endoscopic devices and techniques for the management of bariatric surgical adverse events (with videos)

BACKGROUND AND AIMS

As the prevalence of obesity continues to rise, increasing numbers of patients undergo bariatric surgery. Management of adverse events of bariatric surgery may be challenging and often requires a multidisciplinary approach. Endoscopic intervention is often the first line of therapy for management of these adverse events. This document reviews technologies and techniques used for endoscopic management of adverse events of bariatric surgery, organized by surgery type.

METHODS

The MEDLINE database was searched through May 2018 for articles related to endoscopic management of adverse events of bariatric interventions by using relevant keywords such as adverse events related to "gastric bypass," "sleeve gastrectomy," "laparoscopic adjustable banding," and "vertical banded sleeve gastroplasty," in addition to "endoscopic treatment" and "endoscopic management," among others. Available data regarding efficacy, safety, and financial considerations are summarized.

RESULTS

Common adverse events of bariatric surgery include anastomotic ulcers, luminal stenoses, fistulae/leaks, and inadequate initial weight loss or weight regain. Devices used for endoscopic management of bariatric surgical adverse events include balloon dilators (hydrostatic, pneumatic), mechanical closure devices (clips, endoscopic suturing system, endoscopic plication platform), luminal stents (covered esophageal stents, lumen-apposing metal stents, plastic stents), and thermal therapy (argon plasma coagulation, needle-knives), among others. Available data, composed mainly of case series and retrospective cohort studies, support the primary role of endoscopic management. Multiple procedures and techniques are often required to achieve clinical success, and existing management algorithms are evolving.

CONCLUSIONS

Endoscopy is a less invasive alternative for management of adverse events of bariatric surgery and for revisional procedures. Endoscopic procedures are frequently performed in the context of multidisciplinary management with bariatric surgeons and interventional radiologists. Treatment algorithms and standards of practice for endoscopic management will continue to be refined as new dedicated technology and data emerge.

Endoscopic Full-Thickness Resection for Gastric Subepithelial Lesions Arising from the Muscularis Propria

Most cases of gastric subepithelial lesions follow a good clinical course; however, some lesions progress to malignant tumors, and treatment of tumors with a high risk of malignancy is essential. Surgical excision has been the primary treatment for tumors originating from the propria muscle layer, but it has the disadvantages of being invasive and causing postoperative functional abnormalities. With the development of endoscopic techniques and instruments, the role of endoscopic resection, which is a less invasive method for the removal of gastric subepithelial lesions, has been attracting attention. We performed an endoscopic full-thickness resection for 8 patients with gastric subepithelial lesions originating from the muscularis propria. No fatal complications occurred. Our findings suggest the need to develop various devices for resection and closure and to accumulate further experience through additional studies to prevent complications and specimen loss.

Endoscopic full-thickness resection of early colorectal neoplasms using an endoscopic submucosal dissection knife: a retrospective multicenter study

Background and study aims  Endoscopic full-thickness resection allows resection of early gastrointestinal neoplasms not amenable to conventional endoscopic resection techniques, due to their location, presence of submucosal fibrosis, or suspected deep mural invasion. It is typically achieved using a dedicated over-the-scope device (full-thickness resection device or FTRD). The aim of our study was to evaluate the feasibility, safety, and clinical outcomes of endoscopic full-thickness resection using an endoscopic submucosal dissection (ESD) knife. Patients and methods  Consecutive patients who underwent full-thickness endoscopic resection at six tertiary care centers from August 2010 to June 2017 were retrospectively included. We conducted a comparative analysis of patient characteristics, technical success, adverse events, and time to discharge between patients treated by a full-thickness resection using an ESD knife. Results  Twenty-one procedures were performed using an ESD knife. En-bloc resection and R0 resection rates were 95.2 % and 65 %, respectively. Clinical symptoms of perforation occurred in 66.7 %. There was no need for surgery or additional endoscopic procedures. Conclusion  Endoscopic full-thickness resection of early colorectal neoplasms using an ESD knife might be feasible and safe. It allows complete resection of lesions with no limitation in size. The technique may be preferable to an other-the-scope resection device in lesions larger than 20 mm, and to surgery in selected cases of low-risk T1 colorectal carcinomas, non-lifting adenomas, submucosal tumors, or technically challenging lesion locations.

Endoscopic Suturing Results in High Technical and Clinical Success Rates for a Variety of Gastrointestinal Pathologies

PURPOSE

We report our institution's experience with endoscopic suturing and hypothesize that it has high technical and clinical success.

METHODS

This is a retrospective review of patients who underwent a procedure with the endoscopic suturing system between April 2010 and March 2019. Definitions of technical and clinical success were established for each application.

RESULTS

Overall technical and clinical success in 151 procedures was 97.4% and 74.2%, respectively. Endoscopic suturing was used 24 times to treat leaks or fistulas, with a clinical success rate of 55.6%. The clinical success of stent fixations (11) was 72.7%. Intentional mucosal and submucosal defects were closed 20 times with a clinical success of 83.3%. Iatrogenic perforations (9) were repaired with a clinical success of 87.5%. Marginal ulcers were oversewn (5), with an 80% clinical success rate. Diverticulopexy in the esophagus was clinically successful in two patients. Endoscopic suturing was used in endoscopic sleeve gastroplasty in 10 patients and endoscopic gastrojejunostomy revision in 70 patients; weight loss was observed in both groups at up to 2 and 5 years, respectively.

CONCLUSIONS

Endoscopic suturing was used successfully in numerous situations spanning the gastrointestinal tract with high rates of technical and clinical success.

Endoscopic Suturing Results in High Technical and Clinical Success Rates for a Variety of Gastrointestinal Pathologies

PURPOSE

We report our institution's experience with endoscopic suturing and hypothesize that it has high technical and clinical success.

METHODS

This is a retrospective review of patients who underwent a procedure with the endoscopic suturing system between April 2010 and March 2019. Definitions of technical and clinical success were established for each application.

RESULTS

Overall technical and clinical success in 151 procedures was 97.4% and 74.2%, respectively. Endoscopic suturing was used 24 times to treat leaks or fistulas, with a clinical success rate of 55.6%. The clinical success of stent fixations (11) was 72.7%. Intentional mucosal and submucosal defects were closed 20 times with a clinical success of 83.3%. Iatrogenic perforations (9) were repaired with a clinical success of 87.5%. Marginal ulcers were oversewn (5), with an 80% clinical success rate. Diverticulopexy in the esophagus was clinically successful in two patients. Endoscopic suturing was used in endoscopic sleeve gastroplasty in 10 patients and endoscopic gastrojejunostomy revision in 70 patients; weight loss was observed in both groups at up to 2 and 5 years, respectively.

CONCLUSIONS

Endoscopic suturing was used successfully in numerous situations spanning the gastrointestinal tract with high rates of technical and clinical success.

Use of omental patch and endoscopic closure technique as an alternative to surgery after endoscopic full thickness resection of gastric intestinal stromal tumors: A series of cases

BACKGROUND

Gastrointestinal stromal tumors (GISTs) originate from interstitial cells of Cajal. GISTs can occur anywhere along the gastrointestinal tract. Large lesions have traditionally been removed surgically. However, with recent innovations in advanced endoscopy, GISTs located within the stomach are now removed endoscopically. We describe a new innovative endoscopic technique to close large and hard to access defects after endoscopic full-thickness resection of gastric GISTs.

CASE SUMMARY

We present a series of three patients who were diagnosed with a gastric GIST. All patients underwent full-thickness endoscopic resection. In all cases, for closure of the surgical bed, conventional endoscopic techniques including hemoclips, endoloop and suturing were unsuccessful. We performed a new technique in which we pulled omental fat into the gastric lumen and completely closed the defect using endoscopic devices. All patients performed well post-procedure and computed tomography was carried out one day after the procedures which showed no extravasation of contrast.

CONCLUSION

The omental plug technique may be used as an alternative to surgery in selected cases of gastric perforation.

The Use of the Overstitch to Close Perforations and Fistulas

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.

The Use of the Overstitch for Bariatric Weight Loss

Obesity is a public health pandemic and leading contributor to morbidity and mortality. Endoscopic bariatric therapies have emerged as a viable minimally invasive treatment option to fill the therapeutic gap between conservative and surgical approaches. The ability to reliably place full-thickness sutures throughout the gastrointestinal tract has opened the door to novel endoscopic gastric restrictive procedures. A growing body of literature supports endoscopic sleeve gastroplasty as a safe, effective, and reproducible endoscopic treatment of obesity and metabolic syndrome. In addition, endoscopic sutured revision procedures following gastric bypass and sleeve gastrectomy are now first-line with demonstrable safety and long-term efficacy.

Complications of the Use of the OverStitch Endoscopic Suturing System

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.

The Use of the Overstitch Beyond Bariatric Endoscopy: A Pictorial Description

The overstitch endoscopic suturing system has opened a novel arena in endoscopy. To properly apply endoscopic suturing techniques, it is important to understand suture patterns and the different traction methods available. Applications beyond tissue compression in bariatric endoscopy include: closure, traction and fixation. Closure could be applied to perforations, suture dehiscences, fistulas and stoma reduction. Traction could be applied either as a pulley method to improver resection or as an improved method to decrease a defect size and help pull it into an over the scope clip. Fixation has been mainly used to secure stents.

The Development of the Overstitch System and Its Potentials

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.

The Use of the OverStitch for Bariatric Weight Loss in Europe

Technological advances have permitted minimally invasive treatment of many gastrointestinal diseases. With the advent of endoscopic full-thickness suturing, it has become possible to replicate some of the surgical procedures. Endoluminal bariatric procedures to remodel and reduce the gastric volume similar to surgery is evolving as a treatment option for obesity. Some of these methods also have been extended to treat weight regain after gastric bypass surgery. There is a steep learning curve to gaining proficiency with different endoscopic gastric remodeling or gastroplasty techniques. This article describes a simplified technique of endoscopic sleeve gastroplasty using the OverStitch suturing device.