Post written by Guiqi Wang, MD, from the Department of Endoscopy, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.

This study retrospectively reviewed data from patients who underwent closure of rectal defects using endoscopic hand-suturing (EHS) with clips (EHS-Clips) at the Cancer Hospital of the Chinese Academy of Medical Sciences from October 2022 to May 2023.

EHS-Clips refer to a strategy where defects are sutured as much as possible by EHS first, with clips used to close the remaining parts of defects that cannot be completely sutured. Complete closure was defined as completely apposed defect mucosal rims with no discontinuities by EHS-Clips.

In addition, closure obtained via EHS alone was considered complete suture, but closure obtained via EHS plus additional clips was considered partial suture. The primary outcomes included complete closure rate, delayed bleeding (DB) rate, and sustained closure rate. Logistic regression analyses were performed to identify risk factors for sustained closure. Moreover, 3 endoscopists discussed potential reasons for obstruction of the complete suture.

Currently, timely defect closure is reported as an effective measure to prevent DB after endoscopic submucosal dissection (ESD), but there is still a lack of ideal endoscopic closure methods. EHS developed by Goto et al¹ is based on surgical suturing and has shown some preliminary evidence of efficacy and feasibility for gastric defects.

However, for colorectal defects, there is only 1 report on the efficacy of EHS, and the results may be not quite perfect.

We found that EHS is technically difficult and may be affected by factors including characteristics of defects, experience of endoscopists, and limitations of devices. To improve the complete closure rate and prevent DB, we proposed EHS-Clips and explored their effectiveness for rectal defects after ESD or ESD with myectomy (ESD-ME). To our knowledge, our study is the largest on rectal defects closed using EHS and the first to involve using the strategy of EHS-Clips to close rectal defects after ESD or ESD-ME.

EHS-Clips were shown to be effective in closing rectal defects and preventing DB after ESD or ESD-ME. Although the study’s sustained closure rate is not as high as that of gastric EHS in previous studies, the stitch margin of ≥5 mm was found to be a favorable factor for sustained closure. It also was shown that suturing the muscularis propria and mucosal rim can avoid submucosal dead space.

With the improvement of suturing techniques and strategies, EHS-Clips also may be used for closure of full-thickness defects or other defects at specific sites (eg, colon, duodenum).

In the future, we need to continue to improve the suturing strategy to increase the sustained closure rate, the needle delivery method to prevent needle damage to the intestinal mucosa, and the needle holder design to enable stable needle gripping from more angles. Considering the unique characteristics of EHS (ie, limited operational space, single and narrow channel), we should not confine ourselves to a traditional mindset.

Two types of defects based on whether the circular muscle layer was partially dissected. A, A defect after endoscopic submucosal dissection. The yellow lines represent the circular muscle layer. B, A defect after endoscopic submucosal dissection with myectomy. The yellow lines represent the circular muscle layer, and the red lines represent the longitudinal muscle layer.

Read the full article online.

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1. 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:E111-6. ↩︎