Mucosal Closure Research Articles

Comparing Closure Techniques for Pharyngeal Mucosa After Total Laryngectomy: Manual Suture, Linear Stapler, and Thyroid Gland Flap-A Retrospective Analysis.

Objective: This study aimed to compare the clinical effectiveness of manual suture (group A), linear stapler (group B), and thyroid gland flap (group C) for pharyngeal mucosal closure after total laryngectomy (TL) in laryngeal cancer patients. Methods: The data of laryngeal cancer patients who underwent TL between January 1, 2017, and December 1, 2021, were analyzed. Patients were categorized into group A, group B, and group C based on the closure technique. Various parameters, including general data, hospitalization days, total cost, pharyngeal closure time, pharyngeal fistula, pre- and post-surgical calcium levels, and thyroid function indexes, were compared. Results: The study included 81 patients (mean age: 64.09 ± 9.20 years), the general data of the 3 groups of patients were comparable. Tumor stage and primary tumor location varied significantly among the groups (P = .002 and P < .001, respectively). Group A was more commonly used for advanced-stage tumors with widespread invasion. Group B was primarily used for early-stage tumors localized to the larynx. Group C was preferred for cases with mucosal defects or extensive hypopharyngeal invasion. Group B presented a significantly shorter operation time and slightly lower total cost (P = .006). Pharyngeal fistula incidence was 17.28% (14/81), with comparable rates among the groups [12.35% (10/50) in group A, 12.5% (2/16) in group B, and 13.3% (2/15) in group C]. No dysphagia complications were observed during the 2-to-5-year follow-up. Blood calcium levels and thyroid function indicators showed no significant differences before and after surgery among the 3 groups (P > .05). Conclusion: Thyroid gland flap is a safe option that can be used to repair mucosal defects and close the pharyngeal cavity after TL surgery, but in the absence of mucosal defects and widespread tumor invasion, linear staplers are the most time-efficient method.

Evaluation of the Regenerative Capacity of Demineralized Bone Matrix vs Fat Graft in Alveolar Cleft Model in Albino Rats.

This study was performed to evaluate the regenerative capacity of demineralized bone matrix vs fat graft, both guided by pericardium membrane in alveolar cleft model in albino rats. A total of 72 rats were required in this study. A surgical bone defect with a 7 mm length × 4 mm width × 3 mm depth was created as a model of an alveolar cleft, then the rats were divided randomly into four equal groups each group contained 18 rats: control group (defect only), the membrane group (the defect was covered by the pericardium membrane), the demineralized bone matrix (DBM) group (the defect was filled with DBM guided by pericardium membrane) and fat group (the defect was filled with a fat graft guided by the pericardium membrane). Around 6 rats from each group were euthanized after 2, 4, and 8 weeks. Skulls were scanned with cone beam computed tomography (CBCT) and harvested for histological evaluation with routine H&E immunohistochemical stains (Anti-osteocalcin and Anti-Wnt5a). The data was recorded and statistically analyzed by a two-way ANOVA. The study showed a notable formation of new bone, and expression of OCN and Wnt5a were notably increased by time in the fat group. However, the density of bone grafts and OCN and Wnt5a expression decreased with time in the DBM group. Control and membrane groups showed negative OCN and Wnt5a immune-reactivity in the cleft site. Fat graft results were superior to DBM results with regard to mucosal closure and accelerated bone regeneration, and may represent an effective treatment for alveolar cleft reconstruction. Finding an inexpensive, accessible, biocompatible and easily manipulated treatment for craniofacial reconstruction and fat graft fulfilled the desired aims. Further investigations with prolonged evaluation periods are needed. How to cite this article: Abdel Raouf E, Elsherbini AM, Abdel Salam Yousef Y, et al. Evaluation of the Regenerative Capacity of Demineralized Bone Matrix vs Fat Graft in Alveolar Cleft Model in Albino Rats. J Contemp Dent Pract 2024;25(6):554-562.

Pharyngeal mucosal closure in total laryngectomy: comparison between vertical and T-shaped closure.

The objective of this study was to compare the outcomes vertical and T-shaped pharyngoplasty closure techniques after total laryngectomy (TL) and to evaluate the factors associated with the development of pharyngocutaneous fistula. We performed a retrospective study that included patients with a histopathological diagnosis of laryngeal cancer that underwent TL between 2009 and 2021. Fifty-seven patients were included in the study. A total of 14 patients underwent a vertical closure of the neopharynx (24.6%), while 43 patients underwent a T-shaped closure (74.4%). Pharyngocutaneous fistula was the most common complication, observed in 40.4% of cases (n = 23). No difference in the rate of complications was observed between groups, with the exception of tracheal dehiscence which was reduced in patients with T-shaped closure (n = 2, 4.7% vs. n = 5, 35.7%, p = 0.002). Diabetes mellitus was more frequently observed in patients withthe development of pharyngocutaneous fistula (n = 7, 30.4% vs. n = 3, 8.8%, p = 0.03). Although complicationswere lower in the T-shaped closure group, we could not establish the superiority of either technique.

A new through-the-scope clip with anchor prongs is safe and successful for a variety of endoscopic uses.

Background and study aims Endoscopic through-the-scope clips (TTSC) are used for hemostasis and closure. We documented the performance of a new TTSC with anchor prongs. Patients and methods We conducted a prospective case series of the new TTSC in 50 patients with an indication for endoscopic clipping at three hospitals in the United States and Canada. Patients were followed for 30 days after the index procedure. Outcomes included defect closure and rate of serious adverse events (SAEs) related to the device or procedure. Results Fifty patients had 56 clipping procedures. Thirty-four procedures were clipping after endoscopic mucosal resection (EMR) in the colon (33) or stomach (1), 16 after polypectomy, two for hemostasis of active bleeding, and one each for fistula closure, per-oral endoscopic myotomy mucosal closure, or anchoring a feeding tube. Complete defect closure was achieved in 32 of 33 colon EMR defects and 21 of 22 other defects. All clips were placed per labeled directions for use. In 41 patients (82.0%), prophylaxis of delayed bleeding was reported as an indication for endoscopic clipping. There were three instances of delayed bleeding. There were no device-related SAEs. The only technical difficulty was one instance of premature clip deployment. Conclusions A novel TTSC with anchor prongs showed success in a range of defect closures, an acceptable safety profile, and low incidence of technical difficulties.

Endoscopic hand suturing using a modified through-the-scope needle holder for mucosal closure after colorectal endoscopic submucosal dissection: Prospective multicenter study (with video).

Endoscopic hand suturing (EHS) is a novel technique for closing a mucosal defect after endoscopic submucosal dissection (ESD). We investigated the technical feasibility of colorectal EHS using a modified flexible through-the-scope needle holder. This was a prospective multicenter study conducted at two referral centers between June 2022 and April 2023. This study included colorectal neoplasms 20-50 mm in size located in the sigmoid colon or rectum. A modified flexible through-the-scope needle holder, with an increased jaw width to facilitate needle grasping, was used for colorectal EHS. The primary end-points were sustained closure rate on second-look endoscopy (SLE) performed on postoperative days 3-4 and suturing time for colorectal EHS. Secondary end-points included complete closure rate and delayed adverse events. We enrolled 20 colorectal neoplasms in 20 patients, including four patients receiving antithrombotic agents. The tumor location was as follows: lower rectum (n = 8), upper rectum (n = 2), rectosigmoid colon (n = 4), and sigmoid colon (n = 6), and the median mucosal defect size was 37 mm (range, 21-65 mm). The complete closure rate was 90% (18/20 [95% confidence interval (CI) 68.3-98.8%]), and the median suturing time was 49 min (range, 23-92 min [95% CI 35-68 min]). Sustained closure rate on SLE was 85% (17/20 [95% CI 62.1-96.8%]). No delayed adverse events were observed. EHS demonstrated a high sustained closure rate. Given the long suturing time and technical difficulty, EHS should be reserved for cases with a high risk of delayed adverse events.

Assessment of Early and Late Management of Submental Gunshot Wounds.

Background: Management of submental gunshot wounds is becoming more common and requires complex surgical decisions. Objective: Compare outcomes of early and definitive reconstructive techniques following submental gunshot wounds. Methods: Retrospective chart review evaluated subjects who sustained a self-inflicted submental gunshot. The incidence of complications requiring unplanned operations was compared for early management techniques of skin/soft tissue, bone, and mucosal lining and definitive reconstructive techniques using Fisher's or Pearson Chi-square exact test with p ≤ 0.05 considered statistically significant. Results: The total of 27 patients were included. Early techniques included skin = primary soft tissue closure (n = 19) versus wound vacuum-assisted closure (n = 8); mandible = open reduction internal fixation (ORIF) (n = 19) versus external fixation (n = 8); and oral mucosal lining = primary mucosal closure (n = 20) versus dermal substitute (n = 7). Definitive management included ORIF (n = 10, 37%), ORIF with bone grafting (n = 8, 30%), and microvascular free-flap (n = 9, 33%). The incidence of complications requiring unplanned operation when using dermal substitutes for mucosal lining management was statistically higher than primary closure (p < 0.001); otherwise the complication rates of surgical techniques were equivalent. Conclusion: Several surgical decisions and techniques can be utilized at the time of early and definitive management of submental gunshot wounds. Only the use of dermal substitutes for mucosal lining is associated with a significantly higher rate of unplanned operation.

A first-in-human clinical study of laparoscopic autologous myoblast sheet transplantation to prevent delayed perforation after duodenal endoscopic mucosal dissection

BackgroundThe detection rate of superficial non-ampullary duodenal epithelial tumors (SNADETs) has recently been increasing. Large tumors may contain malignant lesions and early therapeutic intervention is recommended. Endoscopic mucosal dissection (ESD) is considered a feasible treatment modality, however, the anatomical and physiological characteristics of the duodenum create a risk of postoperative perforation after ESD.MethodsTo explore whether myoblast sheet transplantation could prevent delayed perforation after ESD, a first-in-human (FIH) clinical trial of laparoscopic autologous myoblast sheet transplantation after duodenal ESD was launched. Autologous myoblast sheets fabricated from muscle tissue obtained seven weeks before ESD were transplanted laparoscopically onto the serous side of the ESD. The primary endpoints were the onset of peritonitis due to delayed perforation within three days after surgery and all adverse events during the follow-up period.ResultsThree patients with SNADETs ≥ 20 mm in size underwent transplantation of a myoblast sheet onto the serous side of the duodenum after ESD. In case 1, The patient’s postoperative course was uneventful. Endoscopy and abdominal computed tomography revealed no signs of delayed perforation. Despite incomplete mucosal closure in case 2, and multiple micro perforations during ESD in case 3, cell sheet transplantation could prevent the postoperative massive perforation after ESD, and endoscopy on day 49 after transplantation revealed no stenosis.ConclusionsThis clinical trial showed the safety, efficacy, and procedural operability of this novel regenerative medicine approach involving transplanting an autologous myoblast sheet laparoscopically onto the serosa after ESD in cases with a high risk of delayed perforation. This result indicates the potential application of cell sheet medicine in treating various abdominal organs and conditions with minimal invasiveness in the future.Trial registrationjRCT, jRCT2073210094. Registered November 8 2021,https://jrct.niph.go.jp/latest-detail/jRCT2073210094.

Reconstruction for Salvage Laryngectomy With Limited Pharyngectomy

Closure technique for optimization of postoperative and functional outcomes following salvage laryngectomy remains an area of debate among head and neck surgeons. To investigate the association of salvage laryngectomy closure technique with early postoperative and functional outcomes. This retrospective cohort study included patients from 17 academic, tertiary care centers who underwent total laryngectomy with no or limited pharyngectomy after completing a course of definitive radiotherapy or chemoradiotherapy with curative intent between January 2011 and December 2016. Patients with defects not amenable to primary closure were excluded. Data were analyzed from February 14, 2021, to January 29, 2024. Total laryngectomy with and without limited pharyngectomy, reconstructed by primary mucosal closure (PC), regional closure (RC), or free tissue transfer (FTT). Patients were stratified on the basis of the pharyngeal closure technique. Perioperative and long-term functional outcomes were evaluated with bivariate analyses. A multivariable regression model adjusted for historical risk factors for pharyngocutaneous fistula (PCF) was used to assess risk associated with closure technique. Relative risks (RRs) with 95% CIs were determined. The study included 309 patients (256 [82.8%] male; mean age, 64.7 [range, 58.0-72.0] years). Defects were reconstructed as follows: FTT (161 patients [52.1%]), RC (64 [20.7%]), and PC (84 [27.2%]). A PCF was noted in 36 of 161 patients in the FTT group (22.4%), 25 of 64 in the RC group (39.1%), and 29 of 84 in the PC group (34.5%). On multivariable analysis, patients undergoing PC or RC had a higher risk of PCF compared with those undergoing FTT (PC: RR, 2.2 [95% CI, 1.1-4.4]; RC: RR, 2.5 [95% CI, 1.3-4.8]). Undergoing FTT was associated with a clinically meaningful reduction in risk of PCF (RR, 0.6; 95% CI, 0.4-0.9; number needed to treat, 7). Subgroup analysis comparing inset techniques for the RC group showed a higher risk of PCF associated with PC (RR, 1.8; 95% CI, 1.1-3.0) and predominately pectoralis myofascial flap with onlay technique (RR, 1.9; 95% CI, 1.2-3.2), but there was no association of pectoralis myocutaneous flap with cutaneous paddle interposition with PCF (RR, 1.2; 95% CI, 0.5-2.8) compared with FTT with cutaneous inset. There were no clinically significant differences in functional outcomes between the groups. In this study of patients with limited pharyngeal defects, interpositional fasciocutaneous closure technique was associated with reduced risk of PCF in the salvage setting, which is most commonly achieved by FTT in academic practices. Closure technique was not associated with functional outcomes at 1 and 2 years postoperatively.

Potential for expanded application of endoscopic hand suturing: A pilot study of 15 cases.

Endoscopic hand suturing (EHS) was first developed to firmly close a mucosal defect following endoscopic submucosal dissection and has the potential for expanded applications. This study aimed to investigate the feasibility and safety of EHS in various clinical settings. In this single-center pilot study, 15 patients who had diseases with potential indications for EHS were prospectively recruited. Technical success, clinical success after the procedure, and severe EHS-related adverse events (AEs) were evaluated. EHS was applied for defect closure after gastric subepithelial lesion removal under laparoscopic observation (n = 9), defect closure after rectal endoscopic full-thickness resection (EFTR) (n = 2), defect closure after thoracoscopy-assisted esophageal EFTR (n = 1), mucosal closure for gastric ulcer bleeding (n = 1), mucosal closure after peroral endoscopic myotomy (POEM) (n = 1), and postoperative anastomotic leak (n = 1). EHS was completed without severe AEs and the clinical courses were also favorable in 13 patients (87%). The median suturing time was 61 minutes. In patients with POEM and anastomotic leak, EHS was discontinued because of the narrow lumen. In conclusion, EHS appears feasible and safe in situations.

Prospective, multi-centric, international, single-arm, cohort study to assess a synthetic polyamide suture material in oral surgery to close the mucosa - MUCODA study.

ObjectivesThe aim was to collect different clinical parameters systematically and proactively regarding safety, effectiveness, and performance of a nylon monofilament suture under routine clinical practice for oral surgery. MethodsThe study design was prospective, bicentric, international, single-armed, and observational. A non-absorbable suture was applied to close the mucosa after different dental surgical interventions. Main objective was the incidence of combined postoperative complications until suture removal. The 95 % Confidence Interval (Agresti-Coull method) was used to prove the non-inferiority with a pre-specified upper margin of 21.9 %. Secondary variables were intraoperative suture handling, patient pain and satisfaction, wound healing, aesthetic appearance, and bacterial contamination. Results105 patients were enrolled. Complication rate was low (1.9 %), 2 swellings occurred. Pain was present for 1.61 days ± 1.42 after various dental interventions with an average pain level of 20.98 ± 22.60 (VAS). Patients with impacted third molar extraction showed the longest pain duration (6 days) combined with the highest mean pain level of 35.33 ± 30.45 (VAS). Intraoperative suture handling was very good to excellent. Suture removal was done after an average duration of 7.56 ± 2.09 days. Patient's satisfaction was high, and an excellent wound healing was reported by the dentists. Aesthetic appearance only performed in implant patients was rated by oral surgeons with an average of 96.19 ± 3.79 points [min. 80 – max. 100] at 5 months postoperatively. Thread bacterial analysis showed that F. nucleatum was the most present species. ConclusionsOur findings indicate that the non-absorbable, nylon-based monofilament suture used is safe and quite suitable for oral mucosal closure after various dental surgical interventions such as tooth extraction, implant placement and impacted third molar extraction. Clinical significanceThis study showed the safe use of a non-absorbable, nylon-based monofilament suture for different oral surgical interventions under daily routine clinical practice.

Fibrin sealant for closure of mucosal penetration at the oesophagus or cardia during submucosal tunnelling endoscopic resection for gastrointestinal submucosal tumours.

To assess the efficacy and safety of a fibrin sealant for the prevention of leak resulting from mucosal penetration at the esophagus or cardia during a STER procedure to remove gastrointestinal submucosal tumors (SMTs). Between April 2014 and October 2022, a total of 290 patients with oesophageal or cardiac SMTs underwent STER at our centre. We retrospectively identified patients with oesophageal or cardia SMTs who underwent STER and experienced mucosal penetration of the cardia or oesophagus during the procedure. A total of 31 mucosal penetrations in 30 procedures were included. Of the 31 mucosal penetrations, 12 occurred in the cardia, and the other 19 occurred in the oesophagus. All 31 sites received the fibrin sealant to close the mucosal penetration. Clinical characteristics, procedure-related parameters, detailed data of the mucosal penetrations, and treatment outcomes using the fibrin sealant were reviewed for all 30 patients to assess the efficacy and safety of the fibrin sealant for closure of mucosal penetration at the cardia or oesophagus. For the 31 mucosal penetrations, the mean size was 0.08 ± 0.06cm2 (range 0.01-0.25cm2). Mucosal closure using the fibrin sealant was performed successfully in all 31 mucosal penetrations. Of the 31 mucosal penetrations, clips were used in 13 cases. All 30 patients were discharged after a median of 7days (range 4-20day) postoperatively. During a mean 62months (range 6-107months) follow-up, all 31 mucosal penetrations successfully healed without the occurrence of infection, ulcer, oesophagitis, chest infection or abdominal infection. For the closure of mucosal penetration during STER at the cardia or oesophagus, a fibrin sealant is both safe and efficacious. It is necessary to conduct more research on the viability, effectiveness, and safety of using a fibrin sealant to close wider mucosal penetrations.

Management after fibula free flap necrosis in maxillofacial reconstruction

IntroductionFew articles discuss the management of a free fibula flap (FFF) necrosis in maxillofacial reconstruction. Material & methodsBetween 2005 and 2020, 170 FFF were used for maxillofacial reconstruction at the University Hospital of Caen, among which 16 cases suffered total necrosis and flap removal. The authors categorized these 16 cases into three groups based on the proposed salvage treatment and analyzed the post-operative follow-up, including complications, length of hospital stay and delay in radiotherapy. ResultsIn Group A, two patients underwent immediate reconstruction with a new free flap. There were no postoperative complications, and the average hospitalization duration after removal of the first flap was 10 days. In Group B, eleven patients underwent reconstruction with a pedicled musculocutaneous pectoralis major flap. These patients experienced numerous complications, with 73% of them requiring at least one additional surgery, and all of them had an indication for later FFF reconstruction. The average hospitalization duration in this group was 37 days. In Group C, three patients underwent conservative management with debridement and mucosal closure. Two of them experienced complications, and all of them underwent later FFF reconstruction. The average hospitalization duration in this group was 15 days. DiscussionBased on our experience and the literature review, the use of an immediate new free flap appears to be the best approach after the removal of a FFF. This generates shorter healing times and shorter hospitalization stays, and this allows better results in terms of function and aesthetics. At least, this is the approach that causes the least delay for radiation therapy if indicated. The other approaches should only be proposed in case of patient's poor general condition or in case of refuse of the patient.

Randomized trial of gastric and colorectal endoscopic submucosal dissection defect closure comparing a novel through-the-scope suturing system with an over-the-scope suturing system (with video)

Mucosal closure adds time but reduces adverse events associated with endoscopic submucosal dissection (ESD). We aimed to assess the closure time (CT), technical success, and cost-effectiveness between a novel through-the-scope helix tack suture system (TTSS) and the over-the-scope suturing system (OTSS). In this single-center, prospective, randomized trial, all patients undergoing ESD with anticipated closure were randomized 1:1 to TTSS (study group) or OTSS (control group). Primary outcomes were CT and overall CT (OCT; CT+ setup time). Secondary outcomes were rates of technical success, adverse events, and cost-effectiveness. Forty patients were randomized to OTSS (n= 20) or TTSS (n= 20). OTSS and TTSS groups were similar with respect to age, gender, proportion of colorectal polyps, proximal colon polyps, and mean size of the resected specimen (40.9mm vs 40.4mm). The mean CT was 18.4 minutes for OTSS and 23.3 minutes for TTSS (P= .36). The mean OCT was 32 minutes for OTSS and 39.5 minutes for TTSS (P= .36). Closure with a primary device was successful in 17 cases (85%) with OTSS and 18 cases (90%) with TTSS (P= .63). No closure-related intraprocedural adverse events or delayed perforations were noted. Mean cost of closure was significantly lower in the TTSS group for lesions<35mm (P= .008). TTSS was not found to be superior to OTSS with respect to CT and technical and clinical success for closure of gastric and colorectal ESD defects. TTSS is more cost-effective for closure of lesions<35mm. (Clinical trial registration number: NCT04925271.).

Development and initial validation of a video-based peroral endoscopic myotomy assessment tool

Video analysis has emerged as a potential strategy for performance assessment and improvement. We aimed to develop a video-based skill assessment tool for peroral endoscopic myotomy (POEM). POEM was deconstructed into basic procedural components through video analysis by an expert panel. A modified Delphi approach and 2 validation exercises were conducted to refine the POEM assessment tool (POEMAT). Twelve assessors used the final POEMAT version to grade 10 videos. Fully crossed generalizability (G) studies investigated the contributions of assessors, endoscopists' performance, and technical elements to reliability. G coefficients below .5 were considered unreliable, between .5 and .7 as modestly reliable, and above .7 as indicative of satisfactory reliability. After task deconstruction, discussions, and the modified Delphi process, the final POEMAT comprised 9 technical elements. G analysis showed low variance for endoscopist performance (.8%-24.9%) and high interrater variability (range, 63.2%-90.1%). The G score was moderately reliable (≥.60) for "submucosal tunneling" and "myotomy" and satisfactorily reliable (≥.70) for "active hemostasis" and "mucosal closure." We developed and established initial content and response process validity evidence for the POEMAT. Future steps include appraisal of the tool using a wider range of POEM videos to establish and improve the discriminative validity of this tool.

How should we evaluate the efficacy of endoscopic closure appropriately? A black box between interventions and outcomes.

Endoscopic closure has drawn attention owing to the development and clinical introduction of various endoscopic interventions in the gastrointestinal tract. A mucosal closure is expected to prevent postoperative adverse events, such as bleeding and delayed perforation, in endoscopic intraluminal resection, for example endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). Endoscopic full-thickness resection always necessitates a robust and sustained defect closure. Furthermore, gastrointestinal fistula requires a closure method that is less invasive than surgical interventions. Intentionally created defects become wider, deeper, and harder to close with only conventional methods using endoscopic clips owing to therapeutic endoscopic expansion. Therefore, dedicated suturing devices/techniques need to be further developed.

Prospective study on the efficacy of endoscopic through-the-scope tack and suture system for gastric peroral endoscopic myotomy mucosal incision site closure.

Background and study aims Mucosal closure after gastric per-oral endoscopic myotomy (G-POEM) can be difficult due to the thick gastric mucosa. We evaluated the use of a novel through-the-scope (TTS) suture system for G-POEM mucosotomy closure. Patients and methods This was a single-center prospective study on consecutive patients who underwent G-POEM with TTS suture closure between February 2022 and August 2022. Technical success was defined as complete mucosotomy closure with TTS suture alone. On subgroup analysis, we compared performance on TTS suturing between the advanced endoscopist and the advanced endoscopy fellow (AEF) under supervision. Results Thirty-six consecutive patients (median age 60 years, interquartile range [IQR] 48.5-67], 72 % women) underwent G-POEM with TTS suture of the mucosotomy. Median mucosal incision length was 2 cm (IQR: 2-2.5). Mean mucosal closure and total procedure time were 17.5 ± 10.8 and 48.4 ± 16.8 minutes, respectively. Technical success was achieved in 24 patients (66.7 %) and 100 % of the cases were adequately closed with a combination of TTS suture and clips. When compared to the advanced endoscopist, the AEF required > 1 TTS suture system for complete closure significantly more frequently (66.7 % vs. 8.3 %, P = 0.009) and more time for mucosal closure (20.4 ± 12.1 vs. 11.9 ± 4.9 minutes, P = 0.03). Conclusions TTS suturing is effective and safe for G-POEM mucosal incision closure. With experience, technical success is high, and most closures may be achieved using a single TTS suture system alone, which has important cost and time implications. Additional comparative trials with other closure devices are need1ed.

Endoscopic Closure of Iatrogenic Rectal Perforation Using the Tulip Bundle Technique.

CASE REPORT Cleansing enemas are commonly used for constipation, but rectal perforation is a rare complication, with a mean incidence of 0.02%–0.23%.1,2 A 75-year-old woman was referred to the emergency department with severe constipation. Physical examination revealed solid stools in the rectum, and a cleansing enema was applied. Immediately, she presented with abundant hematochezia. Rectosigmoidoscopy revealed a large perforation in the posterior rectal wall because of the tip of the enema. Pelvic computed tomography showed extraluminal air in the perirectal fat, suggestive of rectal perforation (Figure 1). To prevent complications, she was admitted under antibiotics and repeated rectosigmoidoscopy.Figure 1.: Pelvic computed tomography showing perirectal free air and fat stranding, suggestive of rectal perforation.We attempted to close the perforation (Figure 2) using an over-the-scope clip, but it did not adequately fit the defect. Because therapeutical failure was imminent, we performed mucosal closure using a clip-fixed endoloop in a single-channel colonoscope. First, a clip was inserted in the working channel of the endoscope; as an independent device outside the scope, the tip of the endoloop was attached to the clip's teeth; next, the clip and endoloop were housed inside the scope channel until completely hidden, and both the scope and the endoloop were inserted in the rectum. The clip-fixed endoloop was then fixed onto the normal mucosa near the mucosal defect; 3 additional clips were used to anchor the endoloop circumferentially along the tear margins. Finally, the endoloop was tightened to close the perforation (Figure 3). The patient recovered uneventfully and was discharged after 7 days. Two weeks later, only a small scar was identified.Figure 2.: Rectosigmoidoscopy revealing a rectal perforation in the posterior rectal wall.Figure 3.: Endoscopic closure of the rectal perforation after using an endoloop. The endoloop was anchored with clips to the normal mucosa near the perforation's edges and closed in a purse-string fashion.An early approach of rectal perforations is critical to prevent complications and reduce mortality.1 Endoscopic techniques, such as over-the-scope clips or through-the-scope clips, are preferred when surgery has high risk of morbimortality.3 New techniques, such as endoloop, have been increasingly used, but choice depends on the type and size of the perforation, available devices, and endoscopist expertise (Video 1, https://links.lww.com/AJG/C770).4,5 {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1","caption":"Endoscopic closure of iatrogenic rectal perforation after a cleansing enema, by using the tulip bundle technique.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"10.14309/crj.0000000000000898.vid1"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} DISCLOSURES Author contributions: F. Pires acquired data, drafted the manuscript, and performed video editing. AC Carvalho acquired data and performed video editing. R. Araújo was responsible for conception and performance of the endoscopic procedure and critically revised the report. All authors read and approved the final version of the manuscript. F. Pires is guarantor of the article. Financial disclosure: None to report. Informed consent was obtained for this case report.

Incidence of Pharyngocutaneous Fistula After Total Laryngectomy and Its Relationship With the Shapes of Mucosa Closure: A Meta-Analysis.

Background and objectivePharyngocutaneous fistula is the most common complication after total laryngectomy. The aim of this study was to examine the incidence of fistula and the association between fistula and the shape of mucosal closure (T-shaped, vertical, or horizontal closure).MethodA search of English language databases from 1979 to 2021 was undertaken for studies of total laryngectomy that commented on pharyngeal closure techniques and fistulas. Pooled estimates for fistula incidence and odds ratios were calculated.ResultsA total of 24 retrospective studies were included. The pooled fistula rates in primary total laryngectomy were 19.9% with T-shaped closure, 16.1% with vertical closure, and 16.4% with horizontal closure. In salvage total laryngectomy, the pooled fistula rates were 35.1%, 36.1%, and 17.9% with T-shaped, vertical, and horizontal closure, respectively. In the analysis of association, the risk of fistula formation in the T-shaped closure was not significantly different compared to that in the vertical closure, (odds ratio, 0.96; 95% confidence interval, 0.46-2.00). The horizontal closure, when compared to vertical closure, was significantly associated with lower risk of fistula formation (odds ratio, 0.31; 95% confidence interval, 0.12-0.78), but had nonsignificant lower risk of fistula formation when compared to the T-shaped closure (odds ratio, 0.46; 95% confidence interval, 0.19-1.12).ConclusionHorizontal closure seems to be the best closure shape for primary repair after total laryngectomy. However, analysis bias may have occurred because of the lack of well-controlled studies.

Is Upfront Surgical Resection of Stage II MRONJ More Cost Effective than Nonsurgical Therapy?

The 2022 AAOMS update on medication-related osteonecrosis of the jaws (MRONJ) acknowledged the benefit of surgical intervention in its algorithm for the treatment of early stage disease.1 Surgical intervention, when appropriate, has been shown in the literature to have predictably high success rates, close to 95%.2,3 By comparison, nonsurgical treatment has significantly lower success rates when defined as mucosal closure. Medical treatment also risks disease progression, and prolongation of exposed, infected and necrotic bone can significantly affect a patient’s quality of life.

How I Teach It: Per Oral Endoscopic Myotomy (POEM)

Per oral endoscopic myotomy (POEM) is an endoscopic procedure for the management of achalasia. The basic steps of POEM include (1) diagnostic esophagogastroduodenoscopy, (2) mucosotomy, (3) submucosal tunneling, (4) myotomy, and (5) mucosal closure. An educational pathway composed of observation, simulation, intraoperative education, and proctorship can allow endoscopists to safely learn POEM for independent practice.