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.

Publication History

Received: 07 November 2019

Accepted: 04 February 2020

Article published online:
23 March 2020

• References

• 1 Yahagi N, Fujishiro M, Omata M. Endoscopic submucosal dissection of colorectal lesion. Dig Endosc 2004; 16: S178-S181
• 2 Yamamoto H, Kawata H, Sunada K. et al. Successful en-bloc resection of large superficial tumors in the stomach and colon using sodium hyaluronate and small-caliber-tip transparent hood. Endoscopy 2003; 35: 690-694
• 3 Saito Y, Emura F, Matsuda T. et al. A new sinker-assisted endoscopic submucosal dissection for colorectal cancer. Gastrointest Endosc 2005; 62: 297-301
• 4 Oka S, Tanaka S, Saito Y. et al. Local recurrence after endoscopic resection for large colorectal neoplasia: a multicenter prospective study in Japan. Am J Gastroenterol 2015; 110: 697-707
• 5 Kobayashi N, Saito Y, Uraoka T. et al. Treatment strategy for laterally spreading tumors in Japan: before and after the introduction of endoscopic submucosal dissection. J Gastroenterol Hepatol 2009; 24: 1387-1392
• 6 Nakajima T, Saito Y, Tanaka S. et al. Current status of endoscopic resection strategy for large, early colorectal neoplasia in Japan. Surg Endosc 2013; 27: 3262-3270
• 7 Hashiguchi Y, Muro K, Saito Y. et al. Japanese Society for Cancer of the Colon and Rectum (JSCCR) guidelines 2019 for the treatment of colorectal cancer. Int J Clin Oncol 2020; 25: 1-42
• 8 Tanaka S, Kashida H, Saito Y. et al. JGES guidelines for colorectal endoscopic submucosal dissection/endoscopic mucosal resection. Dig Endosc 2015; 27: 417-434
• 9 Saito Y, Uraoka T, Yamaguchi Y. et al. A prospective, multicenter study of 1111 colorectal endoscopic submucosal dissections (with video). Gastrointest Endosc 2010; 72: 1217-1225
• 10 Yamada M, Saito Y, Takamaru H. et al. Long-term clinical outcomes of endoscopic submucosal dissection for colorectal neoplasms in 423 cases: a retrospective study. Endoscopy 2017; 49: 233-242
• 11 Tanaka S, Tamegai Y, Tsuda S. et al. Multicenter questionnaire survey on the current situation of colorectal endoscopic submucosal dissection in Japan. Dig Endosc 2010; 22 (Suppl. 01) S2-8
• 12 Oka S, Tanaka S, Kanao H. et al. Current status in the occurrence of postoperative bleeding, perforation and residual/local recurrence during colonoscopic treatment in Japan. Dig Endosc 2010; 22: 376-380
• 13 Saito Y, Kawano H, Takeuchi Y. et al. Current status of colorectal endoscopic submucosal dissection in Japan and other Asian countries: progressing towards technical standardization. Dig Endosc 2012; 24 (Suppl. 01) 67-72
• 14 Takeuchi Y, Iishi H, Tanaka S. et al. Factors associated with technical difficulties and adverse events of colorectal endoscopic submucosal dissection: retrospective exploratory factor analysis of a multicenter prospective cohort. Int J Colorectal Dis 2014; 29: 1275-1284
• 15 Fujihara S, Mori H, Kobara H. et al. The efficacy and safety of prophylactic closure for a large mucosal defect after colorectal endoscopic submucosal dissection. Oncol Rep 2013; 30: 85-90
• 16 Otake Y, Saito Y, Sakamoto T. et al. New closure technique for large mucosal defects after endoscopic submucosal dissection of colorectal tumors (with video). Gastrointest Endosc 2012; 75: 663-667
• 17 Wang J, Zhao L, Wang X. et al. A novel endoloop system for closure of colonic mucosal defects through a single-channel colonoscope. Endoscopy 2017; 49: 803-807
• 18 Nishizawa T, Akimoto T, Uraoka T. et al. Endoscopic string clip suturing method: a prospective pilot study (with video). Gastrointest Endosc 2018; 87: 1074-1078
• 19 Goto O, Sasaki M, Akimoto T. et al. Endoscopic hand-suturing for defect closure after gastric endoscopic submucosal dissection: a pilot study in animals and in humans. Endoscopy 2017; 49: 792-797
• 20 Sano Y, Tanaka S, Kudo SE. et al. Narrow-band imaging (NBI) magnifying endoscopic classification of colorectal tumors proposed by the Japan NBI Expert Team. Dig Endosc 2016; 28: 526-533
• 21 Matsuda T, Fujii T, Saito Y. et al. Efficacy of the invasive/non-invasive pattern by magnifying chromoendoscopy to estimate the depth of invasion of early colorectal neoplasms. Am J Gastroenterol 2008; 103: 2700-2706
• 22 Saito Y, Otake Y, Sakamoto T. et al. Indications for and technical aspects of colorectal endoscopic submucosal dissection. Gut Liver 2013; 7: 263-269
• 23 Aoki T, Nakajima T, Saito Y. et al. Assessment of the validity of the clinical pathway for colon endoscopic submucosal dissection. World J Gastroenterol 2012; 18: 3721-3726
• 24 Tajiri H, Kitano S. Complications associated with endoscopic mucosal resection: definition of bleeding that can be viewed as accidental. Dig Endosc 2004; 16: S134-S136
• 25 Ogasawara N, Yoshimine T, Noda H. et al. Clinical risk factors for delayed bleeding after endoscopic submucosal dissection for colorectal tumors in Japanese patients. Eur J Gastroenterol Hepatol 2016; 28: 1407-1414
• 26 Okamoto K, Watanabe T, Komeda Y. et al. Risk factors for postoperative bleeding in endoscopic submucosal dissection of colorectal tumors. Oncology 2017; 93 (Suppl. 01) 35-42
• 27 Seo M, Song EM, Cho JW. et al. A risk-scoring model for the prediction of delayed bleeding after colorectal endoscopic submucosal dissection. Gastrointest Endosc 2019; 89: 990-998
• 28 Terasaki M, Tanaka S, Shigita K. et al. Risk factors for delayed bleeding after endoscopic submucosal dissection for colorectal neoplasms. Int J Colorectal Dis 2014; 29: 877-882
• 29 Akintoye E, Kumar N, Aihara H. et al. Colorectal endoscopic submucosal dissection: a systematic review and meta-analysis. Endosc Int Open 2016; 4: E1030-E1044
• 30 Ito S, Hotta K, Imai K. et al. Risk factors of post-endoscopic submucosal dissection electrocoagulation syndrome for colorectal neoplasm. J Gastroenterol Hepatol 2018; 33: 2001-2006
• 31 Yamashina T, Takeuchi Y, Uedo N. et al. Features of electrocoagulation syndrome after endoscopic submucosal dissection for colorectal neoplasm. J Gastroenterol Hepatol 2016; 31: 615-620
• 32 Jung D, Youn YH, Jahng J. et al. Risk of electrocoagulation syndrome after endoscopic submucosal dissection in the colon and rectum. Endoscopy 2013; 45: 714-717
• 33 Lee SP, Sung IK, Kim JH. et al. Effect of prophylactic endoscopic closure for an artificial ulceration after colorectal endoscopic submucosal dissection: a randomized controlled trial. Scand J Gastroenterol 2019; 54: 1291-1299
• 34 Yamasaki Y, Takeuchi Y, Iwatsubo T. et al. Line-assisted complete closure for a large mucosal defect after colorectal endoscopic submucosal dissection decreased post-electrocoagulation syndrome. Dig Endosc 2018; 30: 633-641
• 35 Goto O, Sasaki M, Ishii H. et al. A new endoscopic closure method for gastric mucosal defects: feasibility of endoscopic hand suturing in an ex vivo porcine model (with video). Endosc Int Open 2014; 2: E111-116
• 36 Kantsevoy SV, Bitner M, Mitrakov AA. et al. Endoscopic suturing closure of large mucosal defects after endoscopic submucosal dissection is technically feasible, fast, and eliminates the need for hospitalization (with videos). Gastrointest Endosc 2014; 79: 503-507