A new endoscopic closure method for gastric mucosal defects: feasibility of endoscopic hand suturing in an ex vivo porcine model (with video)

Background and study aims: More secure endoscopic closure techniques for iatrogenic gastric defects are required for safe endoscopic surgery. We developed a novel endoscopic suturing method, endoscopic hand suturing (EHS), of gastric mucosal defects and determined its feasibility and efficacy ex vivo.

Materials and methods: We created 24 mucosal defects (each 2 cm in diameter) by endoscopic submucosal dissection. The following three techniques were tested: EHS with a 3 – 0 barbed suture that was grasped with biopsy forceps (n = 6) or a prototype through-the-scope needle holder (n = 6) by endoscopy, looping with endoloops (n = 6) by endoscopy, and clipping with hemoclips (n = 6) by hand. The mucosal edges were attached to each other at three points. The closure strength was compared among the three groups, and the procedural duration was compared between the EHS and looping groups.

Results: All 12 lesions were completely closed by EHS. The median strength of the closure, measured with a spring scale, was significantly greater in the EHS group (0.74 kg) than in the looping group (0.33 kg, P = 0.0012) or clipping group (0.07 kg, P = 0.0009). The median procedural duration did not significantly differ between the EHS and looping groups (19.7 vs. 19.8 minutes, P = 1.0000). The use of the needle holder significantly reduced the procedural duration compared with the biopsy forceps.

Conclusion: Mucosal defects can be firmly closed with EHS, which may be helpful for establishing a safer and more secure endoscopic surgery.

• References

• 1 Ono H, Kondo H, Gotoda T et al. Endoscopic mucosal resection for treatment of early gastric cancer. Gut 2001; 48: 225-229
• 2 Oyama T, Tomori A, Hotta K et al. Endoscopic submucosal dissection of early esophageal cancer. Clin Gastroenterol Hepatol 2005; 3: 67-S70
• 3 Yahagi N, Uraoka T, Ida Y et al. Endoscopic submucosal dissection using the Flex and the Dual knives. Tech Gastrointest Endosc 2011; 13: 74-78
• 4 Chung IK, Lee JH, Lee SH et al. Therapeutic outcomes in 1000 cases of endoscopic submucosal dissection for early gastric neoplasms: Korean ESD Study Group multicenter study. Gastrointest Endosc 2009; 69: 1228-1235
• 5 Goto O, Fujishiro M, Kodashima S et al. Outcomes of endoscopic submucosal dissection for early gastric cancer with special reference to validation for curability criteria. Endoscopy 2009; 41: 118-122
• 6 Goto O, Fujishiro M, Kodashima S et al. A second-look endoscopy after endoscopic submucosal dissection for gastric epithelial neoplasm may be unnecessary: a retrospective analysis of postendoscopic submucosal dissection bleeding. Gastrointest Endosc 2010; 71: 241-248
• 7 Okada K, Yamamoto Y, Kasuga A et al. Risk factors for delayed bleeding after endoscopic submucosal dissection for gastric neoplasm. Surg Endosc 2011; 25: 98-107
• 8 Toyokawa T, Inaba T, Omote S et al. Risk factors for perforation and delayed bleeding associated with endoscopic submucosal dissection for early gastric neoplasms: analysis of 1123 lesions. J Gastroenterol Hepatol 2012; 27: 907-912
• 9 Ikezawa K, Michida T, Iwahashi K et al. Delayed perforation occurring after endoscopic submucosal dissection for early gastric cancer. Gastric Cancer 2012; 15: 111-114
• 10 Choi KD, Jung HY, Lee GH et al. Application of metal hemoclips for closure of endoscopic mucosal resection-induced ulcers of the stomach to prevent delayed bleeding. Surg Endosc 2008; 22: 1882-1886
• 11 Endo M, Inomata M, Terui T et al. New endoscopic technique to close large mucosal defects after endoscopic mucosal resection in patients with gastric mucosal tumors. Dig Endosc 2004; 16: 372-375
• 12 Lee BI, Kim BW, Kim HK et al. Routine mucosal closure with a detachable snare and clips after endoscopic submucosal dissection for gastric epithelial neoplasms: a randomized controlled trial. Gut Liver 2011; 5: 454-459
• 13 Zaruby J, Gingras K, Taylor J et al. An in vivo comparison of barbed suture devices and conventional monofilament sutures for cosmetic skin closure: biomechanical wound strength and histology. Anesthet Surg J 2011; 31: 232-240
• 14 Demyttenaere SV, Nau P, Henn M et al. Barbed suture for gastrointestinal closure: a randomized control trial. Surg Innov 2009; 16: 237-242
• 15 Patri P, Beran C, Stjepanovic J et al. V-Loc, a new wound closure device for peritoneal closure - is it safe? A comparative study of different peritoneal closure systems. Surg Innov 2011; 18: 145-149
• 16 Olsina-Kissler JJ, Balsells-Valls J, Dot-Bach J et al. Natural orifice transluminal endoscopic surgery (NOTES): initial experimental results. Cir Esp 2009; 85: 298-306
• 17 Maratka Z, Armengol-Miro JR. Endoscopic diagnosis and therapy in gastroenterology. Bad Homburg: Normed Verlag; 2012
• 18 Uedo N, Takeuchi Y, Yamada T et al. Effect of a proton pump inhibitor or an H2-receptor antagonist on prevention of bleeding from ulcer after endoscopic submucosal dissection of early gastric cancer: a prospective randomized controlled trial. Am J Gastroenterol 2007; 102: 1610-1616
• 19 Takizawa K, Oda I, Gotoda T et al. Routine coagulation of visible vessels may prevent delayed bleeding after endoscopic submucosal dissection - an analysis of risk factors. Endoscopy 2008; 40: 179-183
• 20 Goto O, Fujishiro M, Oda I et al. A multicenter survey of the management after gastric endoscopic submucosal dissection related to postoperative bleeding. Dig Dis Sci 2012; 57: 435-439
• 21 Schurr MO, Hartmann C, Ho CN et al. An over-the-scope clip (OTSC) system for closure of iatrogenic colon perforations: results of an experimental survival study in pigs. Endoscopy 2008; 40: 584-588
• 22 Moran EA, Gostout CJ, Bingener J. Preliminary performance of a flexible cap and catheter-based endoscopic suturing system. Gastrointest Endosc 2009; 69: 1375-1383
• 23 von Renteln D, Schmidt A, Vassiliou MC et al. Natural orifice transluminal endoscopic surgery gastrotomy closure with an over-the-endoscope clip: a randomized, controlled porcine study (with videos). Gastrointest Endosc 2009; 70: 732-739
• 24 Pham BV, Raju GS, Ahmed I et al. Immediate endoscopic closure of colon perforation by using a prototype endoscopic suturing device: feasibility and outcome in a porcine model (with video). Gastrointest Endosc 2006; 64: 113-119
• 25 Voermans RP, Worm AM, van Berge Henegouwen MI et al. In vitro comparison and evaluation of seven gastric closure modalities for natural orifice transluminal endoscopic surgery (NOTES). Endoscopy 2008; 40: 595-601