Closure of post-EMR mucosal defects: to need or not to need, that is the question

Abstract

To the Editor: We read with interest the article by Fujii et al1Fujii T. Ono A. Fu K.I. A novel endoscopic suturing technique using a specially designed so-called “8-ring” in combination with resolution clips (with videos).Gastrointest Endosc. 2007; 66: 1215-1220Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar on a novel endoscopic suturing technique to close post-EMR large mucosal defects with a figure-of-8-shaped ring (8-ring) and clips. They previously described another method to close the defects with an endoloop and clips to prevent post-EMR delayed bleeding.2Matsuda T. Fujii T. Emura F. et al.Complete closure of a large defect after EMR of a lateral spreading colorectal tumor when using a two-channel colonoscope.Gastrointest Endosc. 2004; 60: 836-838Abstract Full Text Full Text PDF PubMed Scopus (100) Google Scholar Because the previous technique requires a double-channel colonoscope, they modified the technique to use a single-channel colonoscope, and they closed the defects successfully, without complications, in 10 lesions. We believe that this technique has some drawbacks, and furthermore, we doubt whether the prophylactic closure could effectively prevent delayed bleeding. Large sessile or flat colorectal polyps have a greater malignant potential, and are traditionally treated surgically.3Brooker J.C. Saunders B.P. Shah S.G. et al.Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps: a randomized trial and recommendations.Gastrointest Endosc. 2002; 55: 371-375Abstract Full Text Full Text PDF PubMed Scopus (248) Google Scholar, 4Matsushita M. Hajiro K. Takakuwa H. et al.Which parameter, marginal irregularity or tumor size, is more closely related to a malignant potential in flat elevated type of colorectal tumor?.Gastrointest Endosc. 1999; 50: 306-307Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar EMR is preferable to surgery because of its curability and less invasiveness.3Brooker J.C. Saunders B.P. Shah S.G. et al.Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps: a randomized trial and recommendations.Gastrointest Endosc. 2002; 55: 371-375Abstract Full Text Full Text PDF PubMed Scopus (248) Google Scholar On the basis of the size and location of the polyps, EMR can be performed en bloc or piecemeal. Although piecemeal resection is related to a higher recurrence rate compared with en bloc resection, the piecemeal technique is used most frequently in large polyps.3Brooker J.C. Saunders B.P. Shah S.G. et al.Treatment with argon plasma coagulation reduces recurrence after piecemeal resection of large sessile colonic polyps: a randomized trial and recommendations.Gastrointest Endosc. 2002; 55: 371-375Abstract Full Text Full Text PDF PubMed Scopus (248) Google Scholar We believe that the technique used by Fujii et al1Fujii T. Ono A. Fu K.I. A novel endoscopic suturing technique using a specially designed so-called “8-ring” in combination with resolution clips (with videos).Gastrointest Endosc. 2007; 66: 1215-1220Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar would cover not only large mucosal defects but residual polyp tissue, resulting in a delay of adequate treatment for the recurrence. The risk of post-EMR bleeding and perforation is reported to increase with the size of resected polyps.1Fujii T. Ono A. Fu K.I. A novel endoscopic suturing technique using a specially designed so-called “8-ring” in combination with resolution clips (with videos).Gastrointest Endosc. 2007; 66: 1215-1220Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar Most perforations are small enough to close with immediate clipping,5Taku K. Sano Y. Fu K.I. et al.Iatrogenic perforation associated with therapeutic colonoscopy: a multicenter study in Japan.J Gastroenterol Hepatol. 2007; 22: 1409-1414Crossref PubMed Scopus (148) Google Scholar and the method of Fujii et al1Fujii T. Ono A. Fu K.I. A novel endoscopic suturing technique using a specially designed so-called “8-ring” in combination with resolution clips (with videos).Gastrointest Endosc. 2007; 66: 1215-1220Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar would be useful for perforations too large to close with a simple closure. Although prophylactic clipping to close post-EMR mucosal defects has been recommended for preventing delayed bleeding, the clipping technique has not decreased the occurrence of delayed bleeding in a prospective randomized controlled study.6Shioji K. Suzuki Y. Kobayashi M. et al.Prophylactic clip application does not decrease delayed bleeding after colonoscopic polypectomy.Gastrointest Endosc. 2003; 57: 691-694Abstract Full Text Full Text PDF PubMed Scopus (203) Google Scholar If their excellent technique cannot reduce the complication rate, we believe that the suturing technique might be only more time consuming compared to EMR without suturing.