Endoscopic purse-string suture technique: An effective remedy for a large iatrogenic rectal perforation

A Study of a Novel Disposable Endoscopic Purse-String Suture Auxiliary Instrument for the Treatment of Full-Thickness Gastric Wall Defects

OBJECTIVES

In this study, we aimed to evaluate the effectiveness of a novel endoscopic purse-string suture auxiliary instrument compared with traditional methods for closure of a full-thickness defect of the stomach in an ex vivo model.

METHODS

Twelve perforation sites (10-20 mm in diameter) were created in the ex vivo porcine stomach models. Two physicians (A and B had performed endoscopic surgery for 6 and 3 years) performed suturing using both the experimental and traditional (control) instruments. Operation time, success rate, and number of attempts for successful suture required were recorded.

RESULTS

For physician A, the median suturing time was 56.50 s (interquartile range [IQR] 40.50 s, 134.50 s) and 215.50 s (IQR 63.75 s, 254.75 s) in the experimental and control groups. For physician B, they were 53.00 s (IQR 38.50 s, 87.75 s) and 174.00 s (IQR 104.50 s, 279.25 s), respectively. The differences between experimental and control groups were statistically significant for both physicians A (p = 0.010) and B (p = 0.004). The median number of attempts required for successful suturing in the experimental and control groups was 1 (IQR 1, 2) and 2 (IQR 1, 3) for physician A, and 1 (IQR 1, 1) and 3 (IQR 2, 3) for physician B, which were statistically significant for both physicians (p = 0.026 and 0.006). The overall success rate was significantly higher in the experimental group (100% vs. 75.0%, p = 0.022).

CONCLUSION

This novel purse-string suture auxiliary instrument may assist in single-channel endoscopic suturing operations, improve the suture success rate, reduce the number of operations required, and shorten the operation time.

Feasibility and efficacy of endoscopic purse-string suture-assisted closure for mucosal defects induced by endoscopic manipulations

BACKGROUND

Large or transmural defects induced by gastrointestinal endoscopic manipulations are difficult to close, although complete closure is recommended for better recovery. Endoscopic purse-string assisted suturing (EPSS) has been used in clinical practice and has proven to be an effective and safe technique for the closure of large mucosal defects. However, details regarding the efficacy of endoscopic pre-purse-string suture (P-EPSS) are unknown, especially that it offers several advantages over conventional EPSS (C-EPSS).

AIM

To elucidate the outcomes of EPSS-assisted closure in different clinical situations, and evaluate the efficacy of P-EPSS.

METHODS

This retrospective observational study included a total of 180 patients who underwent closure assisted by P-EPSS (n = 63) or C-EPSS (n = 117) between July 2014 and June 2020. The P-EPSS and C-EPSS groups were compared and the intergroup differences in aspects such as the lesion size, location, and mor-phology, incidence of complete closure, intraoperative perforation, and delayed adverse events were evaluated. Data on the features and clinical course of cases with adverse events were collected for further analysis.

RESULTS

Patients with lesion size larger than 3 cm, lesions located at the fundus of stomach, or submucosal tumors originating from the deep mucosa were more likely to undergo P-EPSS-assisted closure. The P-EPSS group showed a sign-ificantly higher proportion of intraoperative perforation (56% vs 17%) and a much shorter procedure time (9.06 ± 6.14 min vs 14.84 ± 7.25 min). Among adverse events, the incidence of delayed perforation (5% vs 4%; P = 0.82) and delayed bleeding (3% vs 4%; P = 0.96) did not differ significantly between the groups. Multivariate analysis revealed that lesions with incomplete closure [odds ratio (OR) = 21.33; 95% confidence interval (CI): 5.45-83.45; P < 0.01] or size greater than 3 cm (OR = 3.14; 95%CI: 1.08-9.18; P = 0.039) showed a statistical tendency to result in an increase in delayed adverse events.

CONCLUSION

The present study revealed that EPSS could achieve secure complete closure of mucosal defect. P-EPSS could shorten the procedure and yield complete closure of mucosal defects. Rather than closure-type selection, incomplete closure or lesion size larger than 3 cm were associated with worse outcomes.