Low delayed bleeding and high complete closure rate of mucosal defects with the novel through-the-scope dual-action tissue clip after endoscopic resection of large nonpedunculated colorectal lesions (with video)

Colorectal endoscopic submucosal dissection in the USA: The current state and future perspectives

Endoscopic submucosal dissection (ESD) is a transformative advancement in the endoscopic management of superficial gastrointestinal lesions. Initially conceived for the treatment of early gastric cancer, ESD has demonstrated proficiency in achieving en-bloc resection of superficial gastrointestinal lesions. ESD has experienced widespread acceptance in Japan and East Asia; however, its adoption in the USA remains delayed. This initial hesitancy could be attributed to procedural complexity and training demands; nonetheless, recently, ESD has been gaining popularity in the USA. This is due to the advancements in endoscopic technology, tailored training programs, and cumulative evidence regarding the efficacy and safety of ESDs. This review aimed to deliberate the historical progress, current implementation, and prospective trajectory of ESDs in the USA. With ongoing clinical research, technological integration, and educational efforts, ESD is likely to become the gold standard for managing large gastrointesitinal lesions. This progress marks an imperative step toward less invasive, more precise, and patient-centric approaches regarding advanced therapeutic endoscopy in the USA.

Endoscopic management of colonic perforations

PURPOSE OF REVIEW

We will review the current management of colonic perforations, with particular emphasis on iatrogenic perforations caused by colonoscopy, the leading etiology. We will focus on recently developed endoscopic techniques and technologies that obviate morbid emergency surgery (the standard management approach in years past).

RECENT FINDINGS

Colonic perforations are rare but potentially fatal complications of both diagnostic and therapeutic colonoscopy resulting in death in approximately 5% of cases with the mortality increasing with delay in diagnosis and treatment. As novel endoscopic techniques and tools have flourished in recent years, our approach to management of these perforations has evolved. With the availability of newer tools such as over the scope clips, enhanced through the scope clips and novel endoscopic suturing devices, colonic perforations can be managed effectively in many or most patients without the morbidity of surgical interventions.

SUMMARY

With expanding use of colonoscopy, inadvertent outcomes such as perforations are bound to increase as well. Early diagnosis permits minimally invasive, nonsurgical, endoscopic management in most cases if the expertise and tools are available. Centers with high colonoscopy volumes including therapeutic procedures would be well served to invest in the requisite technologies and expertise.

Closure methods for large defects after gastrointestinal endoscopic submucosal dissection

Nowadays, endoscopic submucosal dissection (ESD) is commonly performed for the removal of large gastrointestinal lesions. Endoscopic mucosal defect closure after ESD is vital to avoid adverse events. In recent years, many innovative instruments have emerged and proved to be beneficial. In this paper, we conducted a thorough literature review and summarized the closure methods for large-size post-ESD mucosal defects over decades. We separated these methods into five categories based on the operational principle: "side closure" method, "ring closure" method, "layered closure" method, "hand suturing closure" method, and "specially designed device closure" method. Side closure with clips assisted by instruments such as threads or loops is applicable for each segment of the gastrointestinal tract to prevent postoperative bleeding. If the defect tension is too large to close with the traditional side closure methods, zigzag closure and ring closure could be applied to gather the bilateral defect edges together and achieve continuous closure. In the stomach and rectum with a high risk of submucosal dead space between the submucosa and muscular layers, side closure methods with muscle layer grasping clip or layered closure methods could enable the involvement of the deep submucosa and muscle layers. The ring closure method and specially designed devices including over-the-scope clip, Overstitch, and X-tack could resolve perforation effectively. Individual closure method requires endoscope reinsertion or sophisticated operation, which may be limited by the deep location and the narrow lumen, respectively. Although specially designed devices are expected to offer promising prospectives, the cost-effectiveness remains to be a problem.

The 2023 top 10 list of endoscopy topics in medical publishing: an annual review by the American Society for Gastrointestinal Endoscopy Editorial Board

Using a systematic literature search of original articles published during 2023 in Gastrointestinal Endoscopy (GIE) and other high-impact medical and gastroenterology journals, the GIE Editorial Board of the American Society for Gastrointestinal Endoscopy compiled a list of the top 10 most significant topic areas in general and advanced GI endoscopy during the year. Each GIE Editorial Board member was directed to consider 3 criteria in generating candidate topics-significance, novelty, and impact on global clinical practice-and subject matter consensus was facilitated by the Chair through electronic voting and a meeting of the entire GIE Editorial Board. The 10 identified areas collectively represent advances in the following endoscopic spheres: GI bleeding, endohepatology, endoscopic palliation, artificial intelligence and polyp detection, artificial intelligence beyond the colon, better polypectomy and EMR, how to make endoscopy units greener, high-quality upper endoscopy, endoscopic tissue apposition and closure devices, and endoscopic submucosal dissection. Each board member was assigned a topic area around which to summarize relevant important articles, thereby generating this overview of the "top 10" endoscopic advances of 2023.

Endoscopic suturing and clipping devices for defects in the GI tract

Gastrointestinal luminal defects, including perforations, leaks and fistulae, pose persistent obstacles in endoscopic therapeutic interventions. A variety of endoscopic approaches have been proposed, with through-the-scope clipping (TTSC), over-the-scope clipping (OTSC) and suturing representing the main techniques of tissue apposition. However, the heterogeneity in defect morphology, the technical particularities of different locations in the gastrointestinal (GI) tract and the impact of various parameters on the final outcome, do not allow distinct conclusions and recommendations on the optimal approaches for defect closure, and, thus, current practice is based on endoscopists experience and local availability of devices. This review aims to collect the existing evidence on tissue apposition devices, in order to outline the role of every device on specific indications.

A new through-the-scope clip with anchor prongs is safe and successful for a variety of endoscopic uses

Background and study aims Endoscopic through-the-scope clips (TTSC) are used for hemostasis and closure. We documented the performance of a new TTSC with anchor prongs. Patients and methods We conducted a prospective case series of the new TTSC in 50 patients with an indication for endoscopic clipping at three hospitals in the United States and Canada. Patients were followed for 30 days after the index procedure. Outcomes included defect closure and rate of serious adverse events (SAEs) related to the device or procedure. Results Fifty patients had 56 clipping procedures. Thirty-four procedures were clipping after endoscopic mucosal resection (EMR) in the colon (33) or stomach (1), 16 after polypectomy, two for hemostasis of active bleeding, and one each for fistula closure, per-oral endoscopic myotomy mucosal closure, or anchoring a feeding tube. Complete defect closure was achieved in 32 of 33 colon EMR defects and 21 of 22 other defects. All clips were placed per labeled directions for use. In 41 patients (82.0%), prophylaxis of delayed bleeding was reported as an indication for endoscopic clipping. There were three instances of delayed bleeding. There were no device-related SAEs. The only technical difficulty was one instance of premature clip deployment. Conclusions A novel TTSC with anchor prongs showed success in a range of defect closures, an acceptable safety profile, and low incidence of technical difficulties.

Novel devices for third-space endoscopy procedures

Third-space endoscopy (TSE) is a subspecialty in interventional endoscopy that exploits the submucosa as a working space for the management of various gastrointestinal diseases. Over recent years, TSE has emerged as a viable alternative to surgery for the treatment of various conditions. The rapid dissemination and adoption of TSE has been largely supported by the advent of novel devices aimed to improve the efficacy and safety of these procedures. In this article, we review some of the recent developments in TSE devices and provide our initial experience with these instruments in clinical practice.