Current applications of endoscopic suturing

Table 1 Advantages and disadvantages of different suturing patterns

SuturingPattern	Pros	Cons
Interrupted/ simple	Less tissue drag during tightening of the suture compared to a running suture No risk of suture crossing and entanglement as described for running suture Any failure during suturing would only involve the most recently placed interrupted suture rather than the entire suturing work up to that point as is the case with running sutures Suture failure after termination of the procedure would only involve a small segment of the closure without the risk of dehiscence of the entire closure that exists with running sutures	Approximation of the defect edges occurs as soon as the first interrupted suture is tightened and may limit good visualization and grasping of the edges of the nearly closed defect thus making placement of the subsequent interrupted sutures difficult or inaccurate Substantial increase in cost proportionate to the number of sutures used as discussed under running sutures
Figure of 8	Specialized suture used to close small circular defect in a circular fashion with equal circumferential anisotropic compression towards the center of the defect. Thus, it may be the optimal suturing pattern for fistula closure or oversewing an ulcer containing large vessel(s) at risk for bleeding	Technically more challenging than interrupted sutures Risk of suture entanglement Any suture failure (e.g., erosion through tissue, breakage) would result in slack along the entire suture and result in dehiscence of the entire closure
Running	Allows clear visibilty of the defect edges until the suturing is completed Less expensive as it uses only one suture and cinch (in the United States, for the OverStitch platform, each additional suture+cinch adds approximately $100)	Tissue drag caused by the suture going through multiple bites of tissue requires gentle slow careful technique during tightening of the suture prior to cinching Avoiding entanglement of the long suture leading to the start of the suture line during placement of the transverse sutures across the defect requires careful technique and experience Any error such as accidental drop of the needle, fraying and breakage of the suture or device failure results in loss of the entire work up to that point with the need to start the closure from the beginning Similarly, any suture failure after termination of the procedure (e.g., suture eroding through tissue prematurely or breaking) would result in failure of the entire closure

Table 2 Peroral endoscopic myotomy mucosal tunnel closure comparing endoclips and overstitch

	Endoclip	Overstitch
Total number of patients	62 patients	61 patients
Comparison of 25 consecutive closures
Closure technique (mean number)	8 clips (5-14)	1 suture, 1 cinch, 1 device
Closure duration (mean minutes, P = 0.1)	8.8 min (6-15)	10.1 min (5-16)
Cost analysis (mean dollars, P = 0.2)	$915.84 ($453.81-$2160)	$818
Hospital Stay (mean days, P = 0.1)	1.9 d	1.7 d
Complications	No leaks Increased length of stay (4 d) in one patient with thick mucosal edges approximated with clips and endoloop	No leaks One aborted overstitch closure due to a mucosal tear in the hypopharynx during Overstitch insertion. Had mild sore throat for 4 d

Table 3 Winthrop University Hospital endoscopic suturing registry

Indication	Number of Cases	Comment
POEM submucosal tunnel entry closures	100	100% successful closure Mean closure time: POEM/STER -10 min for a mean 2 cm defect EFTR/ESD -13 min for mean 3 cm defect Perforations/leaks-18 min for mean 1.8 cm defect Complications: No episodes of leakage or wound dehiscence 2 minor adverse events
EFTR of subepithelial tumor intentional defect closures	24
STER submucosal tunnel entry closures	6
ESD	22
Accidental perforation	16
Transoral outlet reduction	7	At mean 34 wk follow-up, mean 19.1 lb weight loss (2-34 lbs)
Primary sleeve gastroplasty	1	At 32 wk follow-up pt lost 40 lbs
Ulcer oversew	1	Required surgical intervention 2 wk post procedure due to lack of response
Leak/fistulae closure	14	2 leaks and 12 fistulas (9 gastric sleeves, 2 roux en y gastric bypass, 1 post- PEG tube removal. 2/2 (100%) leaks and 10/12 (83%) fistulas were successfully closed
Stent anchoring	10	Mean time was 8 min. No episodes of stent migration at mean 8 wk

POEM: Per oral endoscopic myotomy; EFTR: Endoscopic full thickness resection; STER: Submucosal tunnel endoscopic resection; ESD: Endoscopic submucosal dissection.