Gong Rui, Wang Simiao, Song Jiugang, He Zhen, Li Peng, Zhang Shutian, Sun Xiujing
Department of Gastroenterology, Beijing Friendship Hospital, Capital Medical University; National Clinical Research Center for Digestive Diseases; State Key Laboratory of Digestive Health; Beijing Digestive Disease Center; Beijing Key Laboratory for Precancerous Lesion of Digestive Diseases, Beijing, China.
J Gastroenterol Hepatol. 2024 Dec;39(12):2511-2521. doi: 10.1111/jgh.16722. Epub 2024 Aug 22.
Nowadays, endoscopic submucosal dissection (ESD) is commonly performed for the removal of large gastrointestinal lesions. Endoscopic mucosal defect closure after ESD is vital to avoid adverse events. In recent years, many innovative instruments have emerged and proved to be beneficial. In this paper, we conducted a thorough literature review and summarized the closure methods for large-size post-ESD mucosal defects over decades. We separated these methods into five categories based on the operational principle: "side closure" method, "ring closure" method, "layered closure" method, "hand suturing closure" method, and "specially designed device closure" method. Side closure with clips assisted by instruments such as threads or loops is applicable for each segment of the gastrointestinal tract to prevent postoperative bleeding. If the defect tension is too large to close with the traditional side closure methods, zigzag closure and ring closure could be applied to gather the bilateral defect edges together and achieve continuous closure. In the stomach and rectum with a high risk of submucosal dead space between the submucosa and muscular layers, side closure methods with muscle layer grasping clip or layered closure methods could enable the involvement of the deep submucosa and muscle layers. The ring closure method and specially designed devices including over-the-scope clip, Overstitch, and X-tack could resolve perforation effectively. Individual closure method requires endoscope reinsertion or sophisticated operation, which may be limited by the deep location and the narrow lumen, respectively. Although specially designed devices are expected to offer promising prospectives, the cost-effectiveness remains to be a problem.
如今，内镜黏膜下剥离术（ESD）常用于切除较大的胃肠道病变。ESD术后的内镜黏膜缺损闭合对于避免不良事件至关重要。近年来，许多创新器械应运而生并被证明是有益的。在本文中，我们进行了全面的文献综述，并总结了数十年来大尺寸ESD术后黏膜缺损的闭合方法。我们根据操作原理将这些方法分为五类：“侧边闭合”法、“环形闭合”法、“分层闭合”法、“手工缝合闭合”法和“特殊设计器械闭合”法。借助线或环等器械辅助的夹子进行侧边闭合适用于胃肠道的各个部位，以防止术后出血。如果缺损张力过大，无法用传统的侧边闭合方法闭合，可以采用锯齿状闭合和环形闭合来将双侧缺损边缘聚拢在一起，实现连续闭合。在黏膜下层和肌层之间存在黏膜下死腔风险较高的胃和直肠中，使用抓肌层夹的侧边闭合方法或分层闭合方法可以使深层黏膜下层和肌层参与其中。环形闭合方法以及包括套扎器、Overstitch和X-tack在内的特殊设计器械可以有效解决穿孔问题。个别闭合方法需要重新插入内镜或操作复杂，分别可能受到病变位置较深和管腔狭窄的限制。尽管特殊设计器械有望带来良好前景，但成本效益仍是一个问题。
