Prefixed purse-string suture used as a new approach to resect a submucosal tumor in the ileocecal region

Perforation is a significant problem that has hindered the development of endoscopic resection techniques. In 2004, Japanese endoscopists introduced the use of nylon rope and titanium clips to close the perforated wound that resulted from endoscopic mucosal resection (EMR) [1]. More recently, endoscopists have considered substituting “active perforation” for “passive perforation” for lesions where perforation is unavoidable. On this basis, we propose a new method for the endoscopic resection of submucosal tumors to avoid intra-abdominal infection and/or tumor seeding.

A 56-year-old woman attended our department because of a submucosal eminence in the ileocecal part of the intestine that had been found on physical examination ([Fig. 1 a]). An endoscopic ultrasound scan showed a hypoechoic tumor, with a complete envelope, of approximately 4 mm in size in the submucosa ([Fig. 1 b]). As there was no obvious contraindication, it was decided to perform resection by endoscopic submucosal excavation (ESE) ([Video 1]). Studies have however shown that the ileocecal intestinal wall is thin and there is a high risk of perforation during endoscopic treatment [2].

Fig. 1 The submucosal mass in the ileocecal part of the intestine is shown: a on endoscopic view, appearing as a submucosal eminence with a smooth surface; b on endoscopic ultrasound, which suggested the lesion originated from the submucosa and was hypoechoic, with a complete envelope, and a size of approximately 4 mm.

Video 1 A novel resection technique with a prefixed purse-string suture is used for a submucosal ileocecal mass.

The nylon rope was positioned in the ileocecal region under endoscopic guidance, and the shape of the purse-string suture was arranged in advance. After methylene blue had been injected, a circumferential incision was made into the deep layer of the submucosa ([Fig. 2 a]), and further clips were applied to complete the purse-string suture ([Fig. 2 b]). The lesion was then lifted up as a whole ([Fig. 2 c]), so that the tumor could be completely captured by a snare, while the purse-string suture was simultaneously tightened. The snare was used to resect the tumor under endoscopic guidance ([Fig. 2 d] and [Fig. 3]). No muscle layer tissue was left exposed after the operation ([Fig. 2 e]).

Fig. 2 Endoscopic views during resection of the submucosal mass using a novel resection technique using a prefixed purse-string suture showing: a a circumferential incision to the deep submucosa after the purse-string had been previously fixed on one side; b the nylon rope forming the purse-string suture after the placement of further metal clips; c the lesion being lifted as a whole while the purse-string suture is tightened; d the tumor is removed under endoscopic guidance using a snare after the purse-string suture has been tightened; e final appearance of the purse-string suture after resection of the tumor.

Fig. 3 Macroscopic appearance of the resected specimen.

The patient was ordered to follow a liquid diet and bed rest after the endoscopic resection, and she was closely monitored for clinical symptoms associated with abdominal perforation.

The use of the prefixed purse-string suture can therefore completely isolate the digestive tract from the abdominal cavity, avoiding the risk of intra-abdominal infection and/or tumor seeding during the endoscopic resection of submucosal tumors.

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Publikationsverlauf

Artikel online veröffentlicht:
16. Januar 2023

• References

• 1 Matsuda T, Fujii T, Emura F. et al. Complete closure of a large defect after EMR of a lateral spreading colorectal tumor when using a two-channel colonoscope. Gastrointest Endosc 2004; 60: 836-838
• 2 Quallick MR, Brown WR. Rectal perforation during colonoscopic retroflexion: a large, prospective experience in an academic center. Gastrointest Endosc 2009; 69: 960-963