Endo Stitch Placed During Previous Endoscopic Submucosal Dissection of Early Gastric Adenocarcinoma Can Complicate Follow-Up Surveillance

Abstract

Introduction: Endoscopic submucosal dissection (ESD) is emerging as a standard procedure for complete resection and staging of appropriately staged, early, gastric adenocarcinoma. We report a case of 86-year-old male who underwent endoscopic suturing after ESD and then found to have high grade dysplasia (HGD) in the area of endo stitch during follow-up surveillance endoscopy. An 86-year-old male with multiple medical problems was referred for a gastric antral ulcer with HGD and a focus of moderately differentiated adenocarcinoma. EUS indicated the disease to be T1N0 and cross sectional imaging was negative for metastatic disease. He was deemed to be a poor surgical candidate for open gastrectomy and an appropriate candidate for ESD. During the ESD, the entire lesion was dissected off the deeper tissue and resected en bloc. There was no invasive disease into the muscle which appeared clean in all areas. With the Apollo EndoCinch® device and using the standard techniques, 4 interrupted Prolene sutures were applied across the defect in a crisscross pattern and cinched in turn. Three good plications were successful and one failed as the resection site was closed. Pathology revealed a T1a, moderately differentiated adenocarcinoma without lymphovascular invasion and with clear margins. At the 3 month, follow-up surveillance EGD, the previous ESD site had one residual suture left in place which heavily plicated the tissue obscuring the tissue underneath. This was problematic because abnormal tissue was noted to involve this area and the placation device could not be removed despite using several different devices. This abnormal tissue was biopsied in a blind fashion followed by 2 sessions of 20 second, nonoverlapping cryotherapy in 3 sections. Pathology of the residual abnormal tissue showed gastric adenoma with HGD. At a 10-month follow-up, the plication device was still obscuring part of the area of interest and, prior to a second application of cryotherapy; biopsies were taken from this area and again revealed HGD. At 14 months, the device was not there, revealing the tissue underneath i.e. persistent HGD but no higher grade lesion. Older age and antral location of the lesion, as seen in our patient, were previously found to be significant predictors of successful ESD without bleeding. Overstitch® endoscopic suturing device has been shown to be fast, effective and may significantly decrease the treatment cost or length of hospital stay. However, the endoscopist should be cautious if there is high suspicion for possible recurrence of tumor or incomplete resection of tumor as the sutures could potentially obscure tissue which will need to be evaluated during subsequent follow-up EGD.