Tethered ESD – Freehand suturing beyond defect closure

Aims Recently freehand suturing for defect closure became possible by using barbed wire sutures and the availability of a needle holder for the use in flexible endoscopy. We reported about the development of a new technique for tissue traction during ESD using barbed wire sutures. We aimed to characterize the performance of tethered ESD in an ex-vivo porcine stomach model. Here we present preliminary data.

Methods We performed ESD procedures in an ex-vivo porcine stomach with a long adjacent esophageal part. In each stomach 2 resections were performed. We used a 15 mm polypectomy snare and cutting current to mark standardized artificial lesion. This lesion was marked additionally with cauterization markers and resection was performed outside the markers. After initial cut (entry point), the resulting mucosal flap was sutured using a barbed wire suture (3/0, V-LOC 180) and afterwards sutured to the opposite gastric wall proximal to the lesion. Pulling the suture led to traction to the resection specimen thus opening the submucosal space. Due to the nature of the barbed wires, the tension will not loosen once the suture is tightened. Resections were carried out using a hybrid knife with Endocut Q for mucosal incision and Precise-Sec mode for dissection.

Results In total 6 resections were performed. The mean size of specimens was 30 mm±4 mm. Mean duration of resection procedure was 24,6±9,37 min demanding in total 15,5±5,24 needle grasping maneuvers for 4,17±2,14 stiches. In average 2,33±2,31 tension maneuvers were performed. Perforations of the needle trough the serosal layer was not observed and in no case the suture slipped out of the specimen due to tension force. Perforations did not occur. All specimens were resected en-bloc and completely.

Conclusions The method of tethered ESD using barbed wire sutures for gastric ESD is feasible and technically not demanding. It may especially help to resect larger lesions in difficult positions.

Publication History

Article published online:
27 March 2025