Endoscopic Full-Thickness Resection (EFTR) with Sutured Closure of Defect: Wedge Resection for Gastric Tumours

Abstract

Endoscopic Full-Thickness Resection (EFTR) with Sutured Closure of Defect: Wedge Resection for Gastric Tumours Keiichi Ikeda, Paul Swain, Sandy Mosse, Tim Mills, Hisao Tajiri, Annette Fritscher-Ravens Background: Tumours, which extend into the deep submucosa or proximal muscularis propria or further, might be advantageously staged and treated by full thickness resection if secure methods for performing the procedure and closing the defect were available. Full thickness resection would allow more complete histological examination of the cancer and allow less-invasive removal of more deeply penetrating cancers, which have not spread to the serosal surface. A method for rapid closure of full thickness defects in the stomach wall would be valuable for other flexible endosurgical applications. Aims: 1. To test the feasibility of full thickness gastric wedge resection and defect closure. 2. To develop methods for suturing full thickness defects or perforations in the stomach. Materials and Methods: A new sewing method was developed using a flexible sheathed needle with a metal tag and thread at the tip, which passes through the accessory channel. Prototype cutting and knot-tying devices closed the defect after full-thickness resection. Full-thickness wedge resection was achieved by two methods. 1. Aspiration method using a ligating device without submucosal injection with subsequent snare removal. 2. A circumferential cutting method using an insulated tip knife. They were studied in survival experiments in pigs (n=10). A check endoscopy was performed at 7 days after the procedure and again at 21-28 days with subsequent retrieval of the healed defect for further examination at postmortem. At the time of the last endoscopy the EFTR procedure was repeated. Tests of water-tightness and measurements of the force required to pull out the stitches were performed at post-mortem. Results: It was possible to take full-thickness wedge resections from the gastric wall (100%: 20/20) and close the defect after resection using sewing, cutting and knot-tying devices (100%: 20/20). Water tightness at the suturing site was confirmed in experiment at postmortem (100%: 10/10). A healing ulcer at the suturing site was evident at follow-up endoscopy in experiment with survival pigs. The pullout force with stitches using this new sewing method was significantly higher than with endoscopic clips (20.3NG 0.94 vs. 2.2G 0.42, p ! 0.05). There were no serious complications during these experiments. Conclusion: Full-thickness gastric wedge resection with sutured defect closure was feasible and appeared safe in these survival experiments. New methods of sutured defect closure are presented. 221 Novel Procedure of Endoscopic Submucosal Dissection (ESD) Using a New Device (MUCOSECTOME) Yoshiro Kawahara, Atsushi Imagawa, Shigeatsu Fujiki, Yasushi Shiratori Backgrounds: En-bloc resection is beneficial for accurate histological assessment of resected specimen of Endoscopic mucosal resection (EMR). Variable EMR methods were developed. Conventional EMR technique or technique using Cap device method (EMRC) is technically simple and convenient but with this procedure the size of specimen obtained from one-piece resection is very limited. Endoscopic submucosal dissection (ESD) procedure using IT knife, Hook knife, Flex knife, etc. has already reported and it is actually useful to some expert endoscopists of it, but sometimes difficult for general endoscopists to use it safely. We developed a safe and easy technique of the ESD using a new device (Mucosectome, Prototype, Pentax Japan). Device and Methods: Mucosectome is an electrosurgical device, which is newly developed for ESD. Mucosectome is composed with flexible plastic shaft and cutting wire. Traction applied on the handle manipulates the tip of the Mucosectome to assist in the proper alignment of the cutting wire to the tissue. Plastic shaft moves a muscular layer side; cutting wire moves a mucosal layer side of the submucosa during ESD, and then procedure itself becomes safe. Results: 65 cases of early gastric cancer and 5 cases of early esophageal cancer patients received ESD using Mucosectome. En-bloc resection of the lesion succeeded in 67 cases. Dissection of the submucosa was very easily and quickly carried out. Minor bleeding including oozing occurred in 9.8% and no perforation encountered. Conclusion: Here we present a new method of ESD using Mucosectome, which can realize safer, easier, and less time-consuming ESD compared to previous methods. By using this device, general endoscopists may also be able to performe ESD safely.