Closure techniques in exposed endoscopic full-thickness resection: Overview and future perspectives in the endoscopic suturing era

Abstract

Exposed endoscopic full-thickness resection (EFTR) without laparoscopic assistance is a minimally invasive natural orifice transluminal endoscopic surgery technique that is emerging as a promising effective and safe alternative to surgery for the treatment of muscularis propria-originating gastric submucosal tumors. To date, various techniques have been used for the closure of the transmural post-EFTR defect, mainly consisting in clip- and endoloop-assisted closure methods. However, the recent advent of dedicated tools capable of providing full-thickness defect suture could further improve the efficacy and safety of the exposed EFTR procedure. The aim of our review was to evaluate the efficacy and safety of the different closure methods adopted in gastric-exposed EFTR without laparoscopic assistance, also considering the recent advent of flexible endoscopic suturing.

Keywords: Endoscopic full-thickness resection; Endoscopic surgery; Endoscopic suturing; Exposed endoscopic full-thickness resection; Full-thickness resection; Natural orifice transluminal endoscopic surgery.

Figure 1

Technical illustration of the exposed endoscopic full-thickness resection technique with defect closure by means of endoscopic suturing system. A: Endoscopic view of gastric submucosal lesion; B: Precutting and removal of the mucosal and submucosal layer after submucosal injection, in order to expose the tumor; C: Exposed endoscopic full-thickness resection of the tumor and creation of “active perforation”; D and E: Capnoperitoneum management using percutaneously inserted angiocatheter; F: Transmural defect closure with the OverStitch endoscopic suturing system; G: Final apposition of the tissue margins.