Endoscopic full-thickness resection using an endoluminal-suturing device: a proof-of-concept study

Abstract

Background and study aims Endoscopic full-thickness resection (EFTR) is used to achieve R0 resection in difficult situations and as a way to overcome the limitations of endoscopic submucosal dissection. Multiple techniques have been described but adequate tools are still under evaluation. In this study, we evaluated the safety and feasibility of non-exposed endoscopic full-thickness resection using a novel endoscopic suturing device.

Materials and methods Full-thickness resections of gastric predetermined lesions were performed on five pigs using the Endomina platform. After creating virtual lesion > 20 mm, sutures were placed around it using this triangulation platform. After tightening the knots, the bulging lesion, internalized into the gastric lumen, was cut with a needle knife.

Results R0 resections of large lesions (42 to 60 mm) were achieved in all cases. One perforation occurred and prompted us to improve the procedure by shortening the sutures for more maneuverability and reinforcing the suture line before section. Procedure duration dropped by 50 % between the first case and the fourth case. Histological analysis confirmed successful full-thickness resection of all resected specimens.

Conclusion EFTR using this triangulation platform seems feasible for lesions > 20 mm. Additional possible improvements were identified to simplify the procedure before moving to human trials.

• References

• 1 Huang L-Y, Cui J, Lin S-J. et al. Endoscopic full-thickness resection for gastric submucosal tumors arising from the muscularis propria layer. World J Gastroenterol 2014; 20: 13981-13986
• 2 Mori H, Rahman A, Kobara H. et al. Current status of exposed endoscopic full-thickness resection and further development of non-exposed endoscopic full-thickness resection. Digestion 2017; 95: 6-15
• 3 Sumiyama K, Gostout CJ, Rajan E. et al. Submucosal endoscopy with mucosal flap safety valve. Gastrointest Endosc 2007; 65: 688-694
• 4 Kobara H, Mori H, Rafiq K. et al. Submucosal tunneling techniques: current perspectives. Clin Exp Gastroenterol 2014; 7: 67-74
• 5 Lu J, Jiao T, Zheng M. et al. Endoscopic resection of submucosal tumors in muscularis propria: the choice between direct excavation and tunneling resection. Surg Endosc 2014; 28: 3401-3407
• 6 Lu J, Jiao T, Li Y. et al. Facilitating retroflexed endoscopic full-thickness resection through loop-mediated or rope-mediated countertraction (with videos). Gastrointest Endosc 2016; 83: 223-228
• 7 Wang H, Feng X, Ye S. et al. A comparison of the efficacy and safety of endoscopic full-thickness resection and laparoscopic-assisted surgery for small gastrointestinal stromal tumors. Surg Endosc 2016; 30: 3357-3361
• 8 Koo D-H, Ryu M-H, Kim K-M. et al. Asian Consensus Guidelines for the Diagnosis and Management of Gastrointestinal Stromal Tumor. Cancer Res Treat 2016; 48: 1155-1166
• 9 Schmidt A, Bauerfeind P, Gubler C. et al. Endoscopic full-thickness resection in the colorectum with a novel over-the-scope device: first experience. Endoscopy 2015; 47: 719-725
• 10 Marcella C, Shi RH, Sarwar S. Clinical overview of GIST and its latest management by endoscopic resection in upper GI: a literature review. Gastroenterology Research and Practice 2018; 31: 6864256
• 11 Huberty V, Ibrahim M, Hiernaux M. et al. Safety and feasibility of an endoluminal-suturing device for endoscopic gastric reduction (with video). Gastrointest Endosc 2017; 85: 833-837
• 12 Huberty V, Machytka E, Boškoski I. et al. Endoscopic gastric reduction with an endoluminal suturing device: a multicenter prospective trial with 1-year follow-up. Endoscopy 2018; 50: 1156-1162
• 13 Park Y-M, Cho E, Kang H-Y. et al. The effectiveness and safety of endoscopic submucosal dissection compared with endoscopic mucosal resection for early gastric cancer: a systematic review and metaanalysis. Surg Endosc 2011; 25: 2666-2677
• 14 Kim JH, Nam HS, Choi CW. et al. Risk factors associated with difficult gastric endoscopic submucosal dissection: predicting difficult ESD. Surg Endosc 2017; 31: 1617-1626
• 15 Schmidt A, Bauder M, Riecken B. et al. Endoscopic full-thickness resection of gastric subepithelial tumors: a single-center series. Endoscopy 2015; 47: 154-158
• 16 Schmidt A, Beyna T, Schumacher B. et al. Colonoscopic full-thickness resection using an over-the-scope device: a prospective multicentre study in various indications. Gut 2018; 67: 1280-1289
• 17 Kaehler GFBA, Langner C, Suchan KL. et al. Endoscopic full-thickness resection of the stomach: an experimental approach. Surg Endosc 2006; 20: 519-521
• 18 Dobashi A, Rajan E, Knipschield MA. et al. Endoscopic full-thickness resection using suture loop needle T-tag tissue anchors in the porcine stomach (with video). Gastrointest Endosc 2018; 87: 590-596
• 19 Mori H, Kobara H, Fujihara S. et al. Feasibility of pure EFTR using an innovative new endoscopic suturing device: the Double-arm-bar Suturing System (with video). Surg Endosc 2014; 28: 683-690