A novel endoscopic hand-suturing technique for defect closure after colorectal endoscopic submucosal dissection: a pilot study

Abstract

Background This study aimed to demonstrate the feasibility of endoscopic hand-suturing (EHS) and attainability of sustained closure after colorectal endoscopic submucosal dissection (ESD). Methods EHS was defined as uninterrupted endoscopic suturing of the mucosal defect after colorectal ESD using an absorbable barbed suture and a through-the-scope needle holder. Following individual EHS training using an ex vivo porcine colonic model, two experienced endoscopists performed EHS. Repeat colonoscopy was performed on the third or fourth day after ESD to examine the EHS site. The primary end point was the complete EHS closure rate, and secondary end points were sustained closure and post-ESD bleeding rates. Results 11 lesions were included. Median size of the mucosal defect was 38 mm (range 25 – 55 mm) and the lesion characteristics were as follows: lower rectum/upper rectum/ascending colon/cecum = 3/3/2/3, and 0-IIa/0-Is + IIa/others = 5/4/2. EHS was not attempted in two patients owing to difficulty in colonoscope reinsertion after ESD and intraoperative perforation, respectively. EHS was performed for nine lesions, and the complete EHS closure rate was 73 %. Median procedure time for suturing was 56 minutes (range 30 – 120 minutes) and median number of stitches was 8 (range 6 – 12). Sustained closure and post-ESD bleeding rates were 64 % and 9 %, respectively. Conclusions EHS achieved complete and sustained closure in the colorectum. However, EHS is not currently clinically applicable given the long procedure time. Further modifications of the technique and devices are desirable.

Feasibility of endoscopic hand suturing on rectal anastomoses in ex vivo porcine models

“…In five cases, we performed EHS with a continuous suturing method in the same manner as previously introduced 13 . As the first step of EHS, a 3–0 V-loc 180™ absorbable barbed suture (VLOCL0604; Covidien, Mansfield, Massachusetts, USA), which had short barbs to prevent the suture from sliding backward after the tissues being tightened, was delivered through the virtual anus by using the prototype of the flexible needle holder (Olympus) by grasping the thread close to the tail of the needle.…”

“…We developed endoscopic hand suturing (EHS), which is a novel endoscopic suturing technique that allows optimal and secure intraruminal suturing with a curved needle and surgical suture. This technique has been introduced clinically, and is expected for preventing postoperative bleeding after endoscopic submucosal dissection by closing mucosal defects 11 – 13 . We hypothesized that application of EHS for anastomosis to reinforce the anastomosis trans-anally may be useful for reduction of the risk of anastomotic leakage.…”

New Suturing System for Flexible Endoscopy in The Gastrointestinal Tract

“…Duration of Ovesco clip placement in an experienced center averaged 5-10 min (44-47) [8,14]. Clinical experience with a new "through-the-scope" suturing system has been published showing a successful application [17,18]. Some limitation may be possible, since the narrow diameter of the shaft may limit the applicable force transferred to the end-effectors.…”

Successful Management of Pharyngeal Perforation Caused by Overtube Insertion During Endoscopic Submucosal Dissection

“…Further, Wasano et al reported the successful transoral closure of a pharyngeal perforation due to gastrointestinal endoscope insertion [9]. Recently, a flexible endoscopic suturing system (ESS) and endoscopic hand suturing (EHS) have been developed [15][16][17]. If the maneuverability of ESS and EHS are improved, it would be a treatment option for pharyngeal perforation to achieve immediate closure in the future.…”