Double-nylon purse-string suture technique: Another addition to the endoscopist's toolbox for full-thickness defect closure

Abstract

Iatrogenic perforation is the most feared adverse event in endoscopy. With the expansion of interventional endoscopy in favor of traditional surgery, it is now more crucial than ever to develop effective defect closure techniques. This has culminated in the dissemination of multiple novel closure technologies, including through-the-scope clips, over-the-scope clips, through-the-scope suturing and over-the-scope suturing devices. In this editorial, we comment on the recent publication by Wang and colleagues discussing the performance of the double-nylon purse-string suture technique in the closure of large (> 3 cm) gastric full-thickness defects. This technique offers a promising, practical and cost-effective approach to closure of large full-thickness defects that can be readily implemented across diverse healthcare settings.

Key Words: Cancer, Endoscopy, Endoscopic full-thickness resection, Perforation

Core Tip: Endoscopic full-thickness resection requires effective defect closure. In the recent publication by Wang and colleagues, they demonstrate that a novel double-nylon purse-string suture technique is a promising, practical and cost-effective approach for full-thickness defect closure.

INTRODUCTION

Iatrogenic perforation is the most feared adverse event in endoscopy; with reported incidence rates in diagnostic esophagogastroduodenoscopy and colonoscopy of 0.03% and 0.06%, respectively[1-3]. Although the expansion of interventional endoscopy in recent decades has improved patient outcomes and resource utilization it has emphasized the importance of effective defect closure due to the heightened risk of perforation[1,4]. Nowhere is this more apparent than in endoscopic full-thickness resection (EFTR). When applied to gastric subepithelial lesions (SELs), EFTR requires creation of an intentional full-thickness defect in order to achieve R0 resection[5].

DEFECT CLOSURE TECHNIQUES

Multiple defect closure technologies have now been developed including through-the-scope clips (TTSC), over-the-scope clips (OTSC), through-the-scope suturing (TTSS) and OTSC[1,6,7]. This coincides with current consensus guidelines advocating for a first-line endoscopic treatment strategy for iatrogenic perforation management, in preference to surgical intervention[8]. In this issue, Wang et al[9] investigated the performance of a double-nylon purse-string suture technique for the closure of large (> 3 cm) gastric full-thickness defects, following EFTR of gastric SELs. In a retrospective evaluation of 85 patients, all full-thickness defects were successfully closed without surgical treatment. No serious adverse events were noted, with fever (15.3%) and pain (16.5%) noted frequently post-procedure. Surveillance esophagogastroduodenoscopy, at 3-month, 6-month and 12-month intervals noted no evidence of recurrence. These results show that the double-nylon purse-string suturing technique is a promising extension of conventional closure technology for EFTR of gastric SELs.

Where effective intraprocedural perforation closure is becoming increasingly necessary, the innovation of novel defect closure techniques is welcomed. Hayashi[10] first described endoscopic clip closure in 1975, sparking the widespread dissemination of TTSC. The performance of TTSC for iatrogenic perforations has been well-defined[6,11]. However, TTSC do have limitations including opening width and the need for sequential TTSCs. These limitations were aimed to be addressed by OTSC, whereby using a “bear claw” firing mechanism allows for successful defect closure (< 3 cm) with potentially a single OTSC. However, OTSC requires removal and reinsertion of the endoscope, which increases procedure time and the potential risk of peritoneal contamination[11]. Most recently, TTSS and over-the-scope suturing (OTSS) (X-Tack Technology; Overstitch Technology; Apollo Endosurgery; Boston Scientific: Marlborough, Massachusetts, United States) have emerged as novel strategies for defect closure[12,13]. The X-Tack platform is a TTSS device involving four 5-mm surgical steel helix tacks strung on a 3-0 polypropylene suture which can cinch to close large (> 3 cm) defects; similar to the ones described by Wang et al[9]. Given the novel nature of this device, studies with long-term outcomes are necessary, however recent studies show encouraging results, noting complete closure of large perforations with the absence of adverse events[12,13]. The Overstitch endoscopic suturing system involves a needle driver at the tip of the endoscope and a catheter-based suture anchor to allow full-thickness suturing that is subsequently cinched for closure of larger (> 3 cm) defects. Studies have begun to test the safety and efficacy of this technology with promising reports, although generalizable outcomes in non-expert centers remain unknown.

CLINICAL IMPLICATIONS

Given their findings, the authors advocate for the double-nylon purse-string suture technique, as opposed to TTSC, OTSC and the aforementioned endoscopic suturing platforms. Concerns include the ability of TTSC and OTSC to effectively close large (> 3 cm) full-thickness defects, alongside the cost and advanced training to apply TTSS and OTSS. It is clear that comparative analyses are needed, which factor in cost-effectiveness, comparing TTSC, OTSC, TTSS and OTSS; in the hopes of developing a selective algorithm which takes into consideration access to technology, operator expertise, defect location and perforation etiology. However, it is imperative to emphasize the clinical ramifications of unsuccessful defect closure and the morbidity associated with delayed perforation.

CONCLUSION

In conclusion, double-nylon purse-string suture technique shows promise for the closure of large (> 3 cm) full-thickness defects; specifically in endoscopy centers without access to conventional TTSS and OTSS. With the ever-growing movement towards minimally invasive resection techniques, it is imperative for interventional endoscopists to be equipped with the appropriate techniques and practices to safely and effectively achieve defect closure. Double-nylon purse-string technique is an important addition to the arsenal of advanced closure techniques and carries the potential for widespread implementation.