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      Closure of iatrogenic large mucosal and full-thickness defects of the stomach with endoscopic interrupted sutures in in vivo porcine models: are they durable enough?

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          Abstract

          Background

          In this study, we evaluated the technical feasibility of mucosal approximation of large ulcers via an endoscopic suturing system after endoscopic submucosal dissection (ESD), assessed the durability of these sutures, and compared this technique with serosal apposition of full-thickness gastric wall defects using the same device.

          Methods

          Post-ESD ulcers were closed with mucosal apposition in 7 pigs, and endoscopic full-thickness resection (EFTR) defects were closed with serosal apposition in 3 pigs. Pigs recovered for 1 week; they were then euthanized and necropsies were performed.

          Results

          Primary defect closure was achieved in 85.7% of the post-ESD closures and in 100% of the post-EFTR closures ( p = 0.67). All pigs survived for 1 week. At necropsy, sutures had loosened in the post-ESD animals, although only minor deformity of the ulcer edges was observed in all repaired post-ESD ulcers. Meanwhile, all of the post-EFTR defect closures were sustained for 1 week.

          Conclusions

          Primary closure of post-therapeutic defects can be accomplished using the device. Inverted serosal apposition provides a more durable and reliable repair than everted mucosal apposition.

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          Most cited references 33

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          Advantage of endoscopic submucosal dissection compared with EMR for early gastric cancer.

          In EMR of early gastric cancer (EGC), en bloc resection reduces the risk of residual cancer. Endoscopic submucosal dissection (ESD) now allows en bloc resection of large EGCs. To retrospectively determine whether ESD is more advantageous than EMR for EGCs. EMR (825 lesions, 711 patients) or ESD (195 lesions, 185 patients) was performed. The en bloc resection rate, histologically complete resection rate, operation time, complications, and local recurrence rate were studied in relation to ulceration. Hiroshima University Hospital. Subjects comprised 896 patients in whom 1020 EGCs were resected endoscopically from 1990 to 2004. In cases without ulceration, en bloc and histologically complete resection rates were significantly higher with ESD than with EMR, regardless of tumor size. The frequency of ulceration did not differ significantly between groups. Average operation time was significantly longer for ESD than for EMR, regardless of tumor size. Also, regardless of ulceration, the incidence of intraoperative bleeding was significantly higher with ESD (22.6%) than with EMR (7.6%). Delayed bleeding did not differ. In cases with ulceration, the incidence of perforation was significantly higher with ESD (53.8%) than with EMR (2.9%). Local recurrences were treated by incomplete EMR (en bloc, 2.9%; piecemeal, 4.4%). No patient experienced recurrence after ESD. ESD increased en bloc and histologically complete resection rates and may reduce the local recurrence rate. Increased operation time and complication risks with ESD in comparison with EMR remain problematic. Special measures are necessary for ESD of ulcerated lesions to reduce the rates of perforation and incomplete resection.
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            Meta-analysis of endoscopic submucosal dissection versus endoscopic mucosal resection for tumors of the gastrointestinal tract.

             George Gao,  Y. Gao,  Y Cao (2009)
            Endoscopic submucosal dissection (ESD) has been developed to overcome the limitations of endoscopic mucosal resection (EMR). We aimed to compare the outcomes of these two methods. Databases, including Pubmed, EMBASE, and The Cochrane Library, were searched to identify studies comparing ESD with EMR for premalignant and malignant lesions of the gastrointestinal tract. In a meta-analysis, primary end points were the en bloc resection rate and the curative resection rate; secondary end points were operation time, and rates of bleeding, perforation, and local recurrence. 15 nonrandomized studies (seven full-text and eight abstracts) were identified. Meta-analysis showed higher en bloc and curative resection rates (odds ratio [OR] 13.87, 95 %CI 10.12 - 18.99; OR 3.53, 95 %CI 2.57 - 4.84) irrespective of lesion size. Subgroup analysis showed higher en bloc and curative resection rates with ESD for esophageal, gastric, and colorectal neoplasms, and for lesions of size 20 mm. Local recurrence was lower with ESD (OR 0.09, 95 %CI 0.04 - 0.18). But ESD was more time-consuming than EMR (weighted mean difference [WMD] 1.76; 95 %CI 0.60 - 2.92), and showed high procedure-related bleeding and perforation rates (OR 2.20, 95 %CI 1.58 - 3.07; OR 4.09, 95 %CI 2.47 - 6.80). ESD showed better en bloc and curative resection rates and local recurrence compared with EMR, but was more time-consuming and had higher rates of bleeding and perforation complications. These results need to be confirmed by high quality trials and further studies in the west. Copyright Georg Thieme Verlag KG Stuttgart. New York.
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              Endoscopic mucosal resection.

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                Author and article information

                Contributors
                k-masa@outlook.com
                kaz_sum@jikei.ac.jp
                ban1020yamato@yahoo.co.jp
                ad99061@jikei.ac.jp
                ohya@jikei.ac.jp
                thebandapartasiangothic@yahoo.co.jp
                shirooka@jikei.ac.jp
                knakajima@gesurg.med.osaka-u.ac.jp
                tajiri@jikei.ac.jp
                Journal
                BMC Gastroenterol
                BMC Gastroenterol
                BMC Gastroenterology
                BioMed Central (London )
                1471-230X
                22 January 2015
                22 January 2015
                2015
                : 15
                : 1
                Affiliations
                [ ]Division of Gastroenterology & Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8, Nishi-shimbashi, Minato-ku, Tokyo, 105-8461 Japan
                [ ]Department of Endoscopy, The Jikei University School of Medicine, 3-25-8, Nishi-shimbashi, Minato-ku, Tokyo, 105-8461 Japan
                [ ]Department of Pathology, The Jikei University School of Medicine, 3-25-8, Nishi-shimbashi, Minato-ku, Tokyo, 105-8461 Japan
                [ ]Division of Next Generation Endoscopic Intervention, Osaka University, 2-2, Yamadaoka, Suita, Osaka 565-0871 Japan
                Article
                230
                10.1186/s12876-015-0230-5
                4308917
                25608558
                © Kobayashi et al.; licensee BioMed Central. 2015

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                Categories
                Research Article
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                © The Author(s) 2015

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