Endoscopic suturing is superior to endoclips for closure of gastrotomy after natural orifices translumenal endoscopic surgery (NOTES): an ex vivo study

New generation endoscopic closure devices for full-thickness defects: a comparative pre-clinical study (with videos)

BACKGROUND

Endoscopic closure techniques are effective and safe in the management of transmural gastrointestinal defects. However, there is a paucity of data regarding their comparative effectiveness. This study aimed to compare the efficacy and safety of several new-generation, endoscopic closure devices in a pre-clinical model.

METHODS

We evaluated five commercially available devices: a through-the-scope clip (TTSC), an anchor-pronged TTSC, a suturing device, helical tacking system, and over-the-scope clip. We tested closure strength using an ex-vivo porcine model. Next, live animals underwent 15 mm gastric and colonic perforations followed by immediate endoscopic closure with one of the devices. We assessed technical success, 7-day survival, time to complete closure, and National Aeronautical and Space Administration Task Load Index (NASA-TLX) task load index.

RESULTS

A total of 60 ex-vivo closures were conducted (12 per device). The suturing device achieved a higher closure strength than all other devices (P < 0.05 for all comparisons). Technical success was achieved in 80% of cases, and 9 of 10 animals (90%) survived to 7 days post-closure. The mean procedure time for the suturing device was longer than all other devices (P < 0.05 for all comparisons). The mean procedure time for the anchor-pronged TTSC was also faster than over-the-scope clip (P = 0.04). The total endoscopist NASA-TLX score for the suturing device and helical system were greater than all other devices (P < 0.05 for all comparisons).

CONCLUSION

Each closure device varies significantly in closure strength, closure time, and ease of use. Optimal device selection will depend on defect size, anatomic location, the viability of the surrounding tissue, and endoscopist/technician expertise.

Experimental Evaluation of the Optimal Suture Pattern With a Flexible Endoscopic Suturing System

BACKGROUND

The ability to perform reliable, secure endoluminal closure of the gastrointestinal tract wall, is a prerequisite to support the progress of the emerging field of endoluminal surgery. Along with advanced clipping systems, flexible endoscopic suturing devices are commercially available. Current systems can replicate traditional surgical suturing patterns in the endoluminal environment. The aim of this study was to evaluate the optimal endoluminal suturing technique using a flexible endoscopic suturing device.

MATERIALS AND METHODS

Procedures were performed on bench-top simulators containing 20 explanted porcine stomachs. A standardized 3-cm full-thickness incision was created on the anterior wall of each stomach using monopolar cautery. The gastrotomy was closed endoscopically using an over-the-scope suturing device (OverStitch, Apollo Endosurgery; Austin, TX). Three different techniques were used: single stitches, figure-of-8 pattern, and running suture. Material consumption and operation time were recorded and bursting pressure measurement of the closure was performed.

RESULTS

No statistically significant differences were identified in suturing time. Suturing time (minutes) was slightly shorter with the figure-of-8 technique (41.14 ± 4.6) versus interrupted (45.75 ± 1.1) versus continuous (51.44 ± 10.0), but the difference was not statistically significant. The number of sutures required was greater in the interrupted group. No significant difference was found in the burst pressure (mm Hg): figure-of-8 (45.85 ± 26.2) versus interrupted (30.5 ± 22.89) versus continuous (32.0 ± 26.5). In the figure-of-8 group, 85.5% of cases were leakproof above 30 mm Hg, while in the other groups only 50% of cases were so.

CONCLUSION

A figure-of-8 suturing pattern seems to be the preferable suturing technique with the endoscopic suturing device.

Review of Pure Endoscopic Full-Thickness Resection of the Upper Gastrointestinal Tract

Natural-orifice transluminal endoscopic surgery (NOTES) using flexible endoscopy has attracted attention as a minimally invasive surgical method that does not cause an operative wound on the body surface. However, minimizing the number of devices involved in endoscopic, compared to laparoscopic, surgeries has remained a challenge, causing endoscopic surgeries to gradually be phased out of use. If a flexible endoscopic full-thickness suturing device and a counter-traction device were developed to expand the surgical field for gastrointestinal-tract collapse, then endoscopic full-thickness resection using NOTES, which is seen as an extension of endoscopic submucosal dissection for full-thickness excision of tumors involving the gastrointestinal-tract wall, might become an extremely minimally invasive surgical method that could be used to resect only full-thickness lesions approached by the shortest distance via the mouth. It is expected that gastroenterological endoscopists will use this surgery if device development is advanced. This extremely minimally invasive surgery would have an immeasurable impact with regard to mitigating the burden on patients and reducing healthcare costs. Development of a new surgical method using a multipurpose flexible endoscope is therefore considered a socially urgent issue.

Endoluminal full-thickness suture repair of gastrotomy: a survival study

BACKGROUND

Treatment of perforations and complications related to gastrointestinal (GI) surgery and interventional flexible endoscopy is increasingly performed endoscopically. New devices enabling secure full-thickness GI tract closures through flexible endoscopic platforms have been recently developed.

AIM

To assess feasibility of endoscopic closure of a large gastrotomy using a tip-mounted flexible endoscopic suturing device.

METHODS

Six pigs were involved in this study. Standardized 3-cm full-thickness gastrotomies were created endoscopically in various areas of the gastric wall, in all animals, using monopolar cautery. A peritoneoscopy was performed through the gastrotomy. In four pigs, gastrotomy was repaired with an endoscopic suturing device (OverStitch™, Apollo Medical). Full-thickness suturing was started at the edges of the incision, and a figure-of-eight pattern was used. A dedicated helical tissue grasper combined with endoscopic suction was used to retract incision borders and ensure full-thickness closure. Sutures were locked using a cinching device. In two pigs, the gastrotomy was closed laparoscopically and served as a control. An air leak test was performed. On postoperative day 10 (POD 10), all pigs underwent endoscopy and laparotomy and were euthanized.

RESULTS

Mean endoscopic suturing time was 57.5 ± 14.15 min, and four to six sutures were delivered per incision. Laparoscopic suturing time was 8 min. All leak tests were negative. No intraoperative or postoperative complications occurred. On POD 10, all gastrotomies were healed. In one animal, thick adhesions were found surrounding the suture site but no leak was identified.

CONCLUSIONS

Full-thickness suturing of experimental gastrotomies using the OverStitch™ device is feasible and effective.

A Novel Method for Endoscopic Closure of Bladder Perforations During NOTES: Initial Experience from Animal Studies

OBJECTIVES

Translumenal access site closure remains a major challenge in natural orifice translumenal endoscopic surgery (NOTES(®); American Society for Gastrointestinal Endoscopy [Oak Brook, IL] and Society of American Gastrointestinal and Endoscopic Surgeons [Los Angeles, CA]). We assessed the feasibility and safety of using reserved threads to close the bladder perforation during NOTES and analyzed this novel technique in a live porcine model.

MATERIALS AND METHODS

Five female pigs were used in this study. With the animal under general anesthesia, a self-made trocar was inserted into the bladder. Under ureteroscopic guidance, the anterior bladder wall was punctured by a needle into the abdominal wall, and two reserved lines were placed. The bladder perforation was closed with the reserved lines. Procedure time and effectiveness of the closure were recorded and evaluated.

RESULTS

We completed a total of 5 cases of animal experiments. The first case failed because the weight and size of the animal were too large. The remaining 4 cases were successful. The procedure times were 45, 30, 25, and 25 minutes, respectively. The perforations were closed completely.

CONCLUSIONS

The novel method of using reserved thread to close the bladder perforation was safe and effective. Further large-scale survival studies are needed to prove its clinical potential.

Endoscopic full-thickness resection: Current status

Conventional endoscopic resection techniques such as endoscopic mucosal resection or endoscopic submucosal dissection are powerful tools for treatment of gastrointestinal neoplasms. However, those techniques are restricted to superficial layers of the gastrointestinal wall. Endoscopic full-thickness resection (EFTR) is an evolving technique, which is just about to enter clinical routine. It is not only a powerful tool for diagnostic tissue acquisition but also has the potential to spare surgical therapy in selected patients. This review will give an overview about current EFTR techniques and devices.

Natural-orifice transluminal endoscopic surgery

BACKGROUND

Natural-orifice transluminal endoscopic surgery (NOTES) represents one of the most significant innovations in surgery to emerge since the advent of laparoscopy. A decade of progress with this approach has now been catalogued, and yet its clinical application remains controversial.

METHODS

A PubMed search was carried out for articles describing NOTES in both the preclinical and the clinical setting. Public perceptions and expert opinion regarding NOTES in the published literature were analysed carefully.

RESULTS

Two hundred relevant articles on NOTES were studied and the outcomes reviewed. A division between direct- and indirect-target NOTES was established. The areas with the most promising clinical application included direct-target NOTES, such as transanal total mesorectal excision and peroral endoscopic myotomy. The clinical experience with distant-target NOTES, such as for appendicectomy and cholecystectomy, showed feasibility; however, NOTES-specific morbidity was introduced and this represents an important limitation.

CONCLUSION

NOTES experimentation in the preclinical setting has increased substantially. There has also been a significant increase in the application of NOTES in humans in the past decade. Enthusiasm for NOTES should be tempered by the risk of incurring NOTES-specific morbidity. Surgeons should carefully consider patient preferences regarding this new minimally invasive option, as opinions are not unanimously supportive of NOTES. As technical limitations are overcome, the clinical application of NOTES is predicted to increase. It is paramount that, when this complex technique is performed on humans, it is applied judiciously by appropriately trained experts with outcomes recorded in a registry.

New devices and techniques for handling adverse events: claw, suture, or cover?

Increasingly invasive therapeutic endoscopic procedures and laparoscopic surgeries have resulted in endoscopists being challenged more frequently with perforations, fistulas, and anastomotic leakages, for which nonsurgical closure is desired. Devices and techniques are available and in development for endoscopic closure of gastrointestinal wall defects. Currently available devices with excellent clinical success rates include the over-the-scope clip and an endoscopic suturing system. Another device, the cardiac septal defect occluder, has been adapted for use in the gastrointestinal tract. Extensive endoscopic knowledge, a highly trained endoscopy team, and the availability of devices and equipment are required to manage complications endoscopically.

Closing perforations and postperforation management in endoscopy: esophagus and stomach

Luminal perforation after endoscopy is a dreaded complication that is associated with significant morbidity and mortality, longer and more costly hospitalization, and the specter of potential future litigation. The management of such perforations requires a multidisciplinary approach. Until recently, surgery was required. However, nowadays the endoscopist has a burgeoning armamentarium of devices and techniques that may obviate surgery. This article discusses the approach to endoscopic perforations in the esophagus and stomach.