GASTROINTESTINAL EXPOSED ENDOSCOPIC FULL-THICKNESS RESECTION (EO-EFTR) IN THE TIME OF ENDOSCOPIC SUTURING: A NEW START FOR NATURAL ORIFICE TRANS-LUMINAL ENDOSCOPIC SURGERY (NOTES) TECHNIQUES

Aims Eo-EFTR without laparoscopic assistance is a minimally invasive NOTES technique that has shown promising efficacy and safety in the removal of gastrointestinal (GI) submucosal tumors (SMTs) arising from the muscularis propria (MP) and select epithelial tumors (ETs) unsuitable to conventional resection techniques. Wall defect closure was mainly achieved using standard trough-the-scope endoclips or endoclips combined with endoloops. Given the chance of realizing an endosurgical full-thickness sutures, the OverStitch Endoscopic Suturing System (ESS) (Apollo Endosurgery, Austin, Texas, USA) can be used to close wall defects with potentially higher safety and effectiveness. However, data are still limited. The aim of this study was to evaluate the efficacy, safety and feasibility of Eo-EFTR with defect closure by ESS for these lesions.

Methods This was a retrospective, observational cohort study of patients undergoing GI Eo-EFTR without laparoscopic assistance at a single tertiary-referral center.

Results Seven patients (M:F 6:1, age 56±14.5 years) were identified. Indications were: SMTs originating from MP of the stomach (n=2), duodenum (n=2), rectal submucosa (n=1), and rectal ETs (n=2). Mean lesion size was 25±9.9 mm (mean procedure time 164±41 minutes). Eo-EFTR were successfully performed in 6/7 patients. Defect closure with ESS was effective in all cases (6/6 patients). One case was converted into laparoscopic gastric wedge resection because technical unfeasibility. Histopathological examination showed neuroendocrine tumors (n=2), gastrointestinal stromal tumors (n=1), pancreatic heterotopia (n=2), adenoma (n=1) and invasive carcinoma (n=1). We observed a R0 resection in all cases for the exception of one ETs (previously treated by polypectomy) with invasive carcinoma. No major adverse events were observed. Post-procedure hospitalization stay was 4±1.3 days. No macroscopic recurrence was detected at 1-month endoscopic follow-up.

Conclusions GI Eo-EFTR with defect closure by ESS appears to be feasible, effective and safe in referral centres. Further studies are necessary to clarify the role of ESS for post-EFTR wall defect closure.