Introduction

The management of post-interventional and iatrogenic defects in the gastrointestinal tract presents significant challenges in endoscopic practice, often carrying substantial risks for patients. Various closure techniques have been developed, yet consistently effective outcomes remain elusive in diverse scenarios. Endoscopic free-hand suturing (EFHS) using a needle holder is a new technique that has demonstrated potential for effectively addressing these defects. In this study, we present one of the largest cohorts to date, analyzing the safety and feasibility of endoscopic free-hand suturing across multiple scenarios and locations.

Aims & Methods

This study aimed to investigate the feasibility and safety of EFHS and the attainability of sustained closure following various procedures: endoscopic submucosal dissection (ESD), perforation, per-oral endoscopic myotomy (POEM), per-oral endoscopic myotomy for Zenker's diverticulum (Z-POEM), submucosal tunneling endoscopic resection (STER), and endoscopic submucosal excavation (ESE).
ESD, or the respective above-mentioned interventions, were followed by EFHS, utilizing a gastroscope or colonoscope and a barbed absorbable wire (V-loc 180, Covidien, Dublin, Ireland). Needle steering involved a distal cap attachment and a needle holder (SutuArt; Olympus, Hamburg, Germany). Suturing was performed in a zigzag pattern at 5-10 mm intervals. For safety, the needle was concealed, and post-suturing, the remaining suture and needle were cut with a loop cutter (Olympus, Hamburg, Germany) for removal.

Results

In this retrospective single-center study, 30 post-interventional defects in 26 patients (female n = 10, male n = 16) and performed EFHS were retrospectively followed. Technical success, clinical success after the procedure, and severe EFHS-related adverse events were evaluated. EFHS was applied for defect closure after the following interventions and/or complications: colonic endoscopic submucosal dissection (n =10; ceacum n =4, ascending n = 1, transverse n = 2, sigmoid n = 3), rectal endoscopic submucosal dissection (n = 9), gastric subepithelial lesion removal (n = 2; STER n = 1, ESE n = 1) duodenal perforation (n = 1), colonic perforation (n = 1), peroral endoscopic myotomy (POEM) (n = 1), peroral endoscopic myotomy for the treatment of Zenker's diverticulum (Z-POEM) (n = 2). The median of the resected area was 1450 mm² (range 500 – 3600 mm²).
In none of the 26 patients were severe procedure-related events observed, specifically, there were no instances of bleeding or perforation.
Endoscopic follow-up was conducted in 15 of 30 EFHS closures, demonstrating adequate closure in 13 cases, in 2 cases in the rectum, the mucosa was partially dehiscent, although showing re-epithelialization. The median time between the intervention and endoscopic follow-up was 15 days (range 1 - 69 days). The median duration of hospital stay after endoscopic intervention was 2 days (range 1 – 5 days).

Conclusion

Endoscopic free-hand suturing is safe and feasible within the gastrointestinal tract, including esophagus, stomach, duodenum, colon and rectum. Endoscopic free-hand suturing has the potential to enhance the safety of endoscopic interventions and reduce hospital stay duration.

Introduction

Colorectal endoscopic submucosal dissection (ESD) has become a widely used endoscopic technique for superficial colorectal tumors resection. ESD has a higher en bloc resection rate particularly for large lesions than endoscopic mucosal resection (EMR). Thus, ESD is associated with a better curability and can facilitate an adequate histological evaluation. However, the high incidence of postoperative adverse events, such as delayed bleeding, delayed perforation, and post-ESD electrocoagulation syndrome (PECS), which are associated with larger mucosal defects after ESD, has been a cause of concern. Recent meta-analyses have reported that the incidence of postoperative adverse events after ESD was higher than that after EMR.¹ Therefore, these events should be controlled. Various closure techniques have been used to close larger mucosal defects in ESD.² However, the efficacy of these closure techniques in preventing adverse events remains controversial. Furthermore, few studies have been conducted to evaluate a single closure technique with a substantial number of cases.
In some cases, closure of mucosal defects after colorectal ESD is performed using a double-layered suturing technique with conventional hemostatic clips.³ In this technique, the muscle layer is first grasped directly with clips and tented inward, and then the mucosal layer is closed. Therefore, this technique has the potential to provide more reliable closure and prevent the spread of inflammation and abdominal pain than methods that merely close the mucosal layer.

Aims & Methods

This study retrospectively evaluated the impact of closure using a double-layered suturing technique on postoperative adverse events.
In total, 370 lesions in 317 patients who underwent colorectal ESD were included in this analysis. Then, patients with 197 lesions that were completely closed were assigned to the closure group. Meanwhile, patients with 173 lesions including 55 that were partially closed and 118 that were not closed were assigned to the non-closure group. Propensity score matching was performed and 136 lesions were selected for each group.

Results

The closure group had a significantly lower overall incidence rate of postoperative adverse events including delayed bleeding, delayed perforation and post-ESD electrocoagulation syndrome than the non-closure group (2.2% vs. 9.6%, p = 0.018). The closure group had a significantly lower incidence of abdominal pain on the day after ESD than the non-closure group (2.9% vs. 11.0%, p = 0.015).

Conclusion

Prophylactic closure of mucosal defects after colorectal ESD using a double-layered suturing technique could prevent postoperative adverse events and abdominal pain on the day after ESD.

References

1 Wang N, Shu L, Liu S, et al. Comparing endoscopic mucosal resection with endoscopic submucosal dissection in colorectal adenoma and tumors: Meta-analysis and system review. PLoS One 2023;18:e0291916.
2 Kobara H, Tada N, Fujihara S, Nishiyama N, Masaki T. Clinical and technical outcomes of endoscopic closure of postendoscopic submucosal dissection defects: Literature review over one decade. Dig Endosc 2023;35:216-231.
3 Tanaka S, Toyonaga T, Obata D, Ishida T, Morita Y, Azuma T. Endoscopic double-layered suturing: a novel technique for closure of large mucosal defects after endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD). Endoscopy 2012;44 Suppl 2 UCTN:E153-154.

Introduction

Endoscopic submucosal dissection (ESD) is a highly effective and safe technique for the resection of superficial colorectal neoplasms, but it can still be technically challenging for lesions in contact with or invading the appendiceal orifice. Until recently, appendicular lesions were considered unresectable or difficult to resect by endoscopy because of the high risk of incomplete resection, perforation or acute appendicitis. Small studies have reported ESD feasibility and efficacy in this particular context, including for lesions deeply invading the appendix. However, strong data about these more complex resections is lacking and the best management strategy for this kind of lesion remains a matter of debate, with upfront surgery still being the first-choice treatment in most western countries.

Aims & Methods

With the present study, we aimed to assess and report the outcomes of ESD for the treatment of lesions in contact with or invading the appendiceal orifice. We prospectively collected data of ESD procedures for appendiceal neoplasia in a multicenter prospective register. En Bloc R0 resection rate was the primary outcome. Morbidity and additional surgery were also reported.

Results

A total of 112 patients were included, comprising 47 (42%) with previous appendectomy. Fifty-six lesions (50%) were type 3 according to Toyonaga classification (15 (13.4%) post-appendectomy). En-bloc and R0 resection rates were 86.6% and 80.4%, with no significant difference associated with different grades of appendiceal invasion (p=0.9 and p=0.4, respectively) or history of previous appendectomy (p=0.3 for both). Curative resection rate was 78.6%. Additional surgery was performed in 16 (14.3%) cases, with 10/16 (62.5%) corresponding to Toyonaga type 3 lesions (p=0.04). This included the treatment of 5 (4.5%) cases of delayed perforation and 1 acute appendicitis. A second case of acute appendicitis and 1 of delayed hemorrhage also observed, both treated conservatively.

Conclusion

To our knowledge, this is the largest reported series of ESDs for the treatment of appendicular lesions. Our results show that ESD is safe and effective in this context, and should thus be considered as a valuable treatment option. New traction strategies and devices should make it progressively less technically challenging and more widely accessible.

Introduction

Treatment of complex fistula and residual anastomotic insufficiencies remain a challenge even in an interdisciplinary setting. Endoscopic standard techniques for closure like clips, OTSC or SEMS are limited to special indications. Endoscopic suturing may offer an approach to close complex fistula orifices.

Aims & Methods

Endoscopic suturing was used for interventional closure of complex insufficiencies in the lower GI-tract. 5 consecutive patients were treated using standard Endosuturing (SutuArt, Olympus) or modified suture strategy using an additional working channel (ACEES). In three patients residual insufficiencies in the rectum were visible after complex vacuum therapy. In one patient a recto-vaginal fistula was clinical apparent. In one patient an iatrogenic perforation was occurred within dilation therapy for anastomotic stenosis. Due to size or location of the defects a standard closure technique was either not applicable or failed in a prior attempt.

Results

Technical success, defined as macroscopic defect closure, was achievable in 5 of 5 patients. Mean time for intervention was 57(±14)min. For 3 patients bimanual work using additional working channel enhanced endoscopic suturing (ACEES) was performed. In endoscopic surveillance permanent closure was achieved in 4 of 5 patients.

Conclusion

Endoscopic suturing is a newly available technique. Beyond its basic indication for defect closure after ESD this procedure, also in combination with bimanual suturing (ACEES), may offer an excellent opportunity for treatment of complex fistula.

Disclosure

nothing to disclose

Introduction

Endoscopic submucosal dissection (ESD) is a valuable technique for the en-bloc resection of superficial neoplasms in the anal canal. However, its safety and efficacy in patients who have previously undergone transanal endoscopic surgery (TES) —such as transanal minimally invasive surgery (TAMIS) and transanal endoscopic microsurgery (TEM)—remain unclear.

Aims & Methods

To assess the safety and outcomes of ESD in the anal canal for patients with a history of TES compared to naïve patients.
A retrospective analysis was conducted at our tertiary center on 51 patients who underwent ESD in the anal canal between March 2010 and November 2024. Patients with a history of transanal endoscopic surgery were compared to those undergoing ESD as their primary treatment. Key parameters, including resection speed, perforation rates, coagrasper usage, inpatient status, late hemorrhage, and recurrence, were evaluated. Statistical analysis was performed to determine significant differences between groups.

Results

Histological examination confirmed the following cases: 3 adenocarcinomas (including 1 non-curative ESD), 15 adenomas with high-grade dysplasia, 11 adenomas with low-grade dysplasia, 2 sessile serrated lesions, 15 sessile serrated lesions with dysplasia, 2 high-grade intraepithelial lesions, 2 low-grade intraepithelial lesions.
The median resection velocity was slightly lower in patients with recurrence (16.01 mm²/min) compared to those without recurrence (25.56 mm²/min), though this difference did not reach statistical significance (p = 0.062). Perforation occurred in 9.62% of cases, with similar rates between groups (p = 0.58), suggesting that prior TEM does not significantly increase the risk of this complication. Late hemorrhage was observed in 7.84% of patients, again without a significant difference between groups (p = 0.29).
The only statistically significant finding was the smaller lesion size in patients with recurrence (1,162 mm² vs. 2,250 mm², p = 0.045). This is likely due to intensive post-TEM surveillance, which allowed for early detection of recurrence before lesions could grow larger. Other factors, including sex, age, use of coagrasper during the procedure, en-bloc resection, R0 status, and inpatient admission rates, showed no significant differences between groups.

Conclusion

ESD in the anal canal after prior TES appears to be a safe and feasible procedure, with outcomes statistically comparable to those in naïve patients. Although absolute numbers suggest differences, particularly in lesion size, these findings may be influenced by the small sample size. Larger studies are needed to confirm these results and further evaluate long-term efficacy.

Introduction

Endoscopic closure of mucosal defects following colorectal endoscopic submucosal dissection (ESD) helps prevent delayed complications. The Sure Clip Traction Band, a recently developed traction device for endoscopic procedures, features a silicone ring attached to the clip's base, allowing for traction between clips. We have developed a traction-band-assisted endoscopic closure (TBEC) method using the Sure Clip Traction Band [1]. In TBEC, tension between the clips at both ends of the mucosal defect narrows the defect, facilitating the placement of additional clips.

Aims & Methods

We conducted a prospective study to evaluate the feasibility of TBEC in colorectal ESD. Patients with 20-50mm colorectal neoplasms were enrolled. Patients underwent TBEC following the completion of ESD. The primary outcome was the complete closure rate. Secondary outcomes included closure time, number of devices required, and complication rate. The sample size was calculated to be 34 cases based on previous data.

Results

Thirty-four patients were enrolled across three institutions. Data are shown as median (IQR), if applicable. The median age was 75 years (72-80), with a male-to-female ratio of 19:15. Lesion locations were the right colon, left colon, and rectum in a ratio of 22:10:2, respectively. The median lesion diameter was 30 mm (25-35). All ESDs achieved en-bloc resection. The complete closure rate was 100% (34/34). The median closure time was 15 minutes (10-22). The number of devices used was one (1-2) traction band and eight (7-10) clips. Procedure-related complications included intraoperative perforation in 5.8% (2/34), delayed bleeding in 2.9% (1/34), and post-ESD electrocoagulation syndrome in 3.1% (1/32, excluding intraoperative perforation).

Conclusion

A high complete closure rate of mucosal defects following colorectal ESD was achieved using TBEC. Further studies are required to verify the efficacy of TBEC in preventing delayed complications.

References

[1] Maehara K, Esaki M, Sumida Y, Fukuda SI, Minoda Y, Ihara E, Akiho H. Complete closure of mucosal defect after colonic endoscopic submucosal dissection using clip with a silicone traction band. Endoscopy. 2022 Dec;54(S 02):E1005-E1006. doi: 10.1055/a-1889-4838. Epub 2022 Aug 4. PMID: 35926530; PMCID: PMC9736829.

Introduction

Perforation is the most feared endoscopy-related adverse event. Various closure techniques are now available including through-the-scope clips (TTSC), over-the-scope clips (OTSC) and over-the-scope suturing (OTSS).^1,2​​​​ Given the lack of comparative performance estimates, we sought to systematically appraise TTSC, OTSC and OTSS performance for iatrogenic perforation.

Aims & Methods

MEDLINE and EMBASE were independently searched between 06 / 1947 – 01 / 2024 for citations evaluating TTSC, OTSC or OTSS performance. Technical success was defined as complete apposition of the borders of the defect with visual confirmation. Clinical success was defined as technical success with lack of further intervention. Pooled estimates using random-effects modelling were generated stratified by closure modality, location, perforation etiology, and time (year of publication).

Results

Thirty seven citations assessing 795 perforations were included. Pooled technical success and clinical success were 91.5% (95% confidence interval [CI] 87.9-94.1%; I² = 26%) and 86.3% (95% CI 81.9-89.8%; I² = 39%). Technical success of TTSC, OTSC and OTSS were 89.3% (95% CI 82.6-93.6%), 90.7% (95% CI 86.0-93.9%) and 94.9% (95% CI 83.8-98.5%; p=0.53). Clinical success of TTSC, OTSC and OTSS was 85.3% (95% CI 77.9-90.6%), 86.2% (95% CI 80.4-90.5%) and 94.9% (95% CI 83.8-98.5%) (p=0.24). Clinical success was significantly higher for tissue resection-related perforations (p = 0.02) and for perforations in the stomach (p < 0.04); no difference in clinical success was identified when stratifying by closure modality and time (all p > 0.05).

Conclusion

TTSC, OTSC and OTSS are effective for iatrogenic perforation management; specifically, tissue-resection related perforations and perforations in the stomach. No difference in performance was identified based on closure modality or time.

References

1: Paspatis GA, Arvanitakis M, Dumonceau J-M, et al. Diagnosis and management of iatrogenic endoscopic perforations: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement – Update 2020. Endoscopy 2020;52:792-810.
2: Lee JH, Kedia P, Stavropoulos SN, et al. AGA Clinical Practice Update on Endoscopic Management of Perforations in Gastrointestinal Tract: Expert Review. Clin Gastroenterol Hepatol 2021;19:2252-2261.e2.

Disclosure

Eric Lam: Speaker Honorarium: Olympus, Pharmascience
Michael Bourke: Research Support: Olympus, Cook Medical, Boston Scientific.
Neal Shahidi: Speaker Honorarium: Boston Scientific, Pharmascience.
All other authors have no conflicts of interest to disclose.