Keywords
Endoscopy Upper GI Tract - Endoscopic resection (ESD, EMRc, ...) - Endoscopy Lower
GI Tract - Endoscopic resection (polypectomy, ESD, EMRc, ...) - GI surgery
Introduction
Endoscopic submucosal dissection (ESD) has revolutionized treatment of early-stage
gastrointestinal cancer by offering a minimally invasive approach with demonstrable
superiority over endoscopic mucosal resection (EMR) in terms of en bloc resection
and decreased recurrence rates [1]
[2]
[3]
[4]. Yet the promise of ESD is not without its challenges. The procedure inherently
poses a considerable risk of complications, including delayed bleeding and perforation,
due to the potential for significant mucosal defects [5]
[6]. Post-ESD complications contribute significantly to the patient and hospital burden,
requiring additional interventions such as repeat endoscopy, hemostasis, possible
blood transfusion, and extended hospitalization [7]
[8]. Thus, development and implementation of effective preventive measures against these
complications are necessary.
A randomized controlled trial revealed that endoscopic strategies for closing mucosal
defects following ESD have been observed to effectively decrease postoperative adverse
events (AEs) [9]. A variety of closure techniques have emerged, such as clip-based techniques and
endoscopic suturing techniques including the overstitch device, endoscopic hand-suturing
(EHS) system, and endoscopic tack-and-suture device [10]
[11]. While use of clip-based techniques for closing mucosal defects post-ESD has been
widespread, limitations of these techniques, including their restricted tissue grasp
and associated risk of early-stage mucosal dehiscence, have necessitated exploration
of alternative methods [12]
[13]. These limitations have spurred exploration of alternate methods, such as endoscopic
suturing. Kantsevoy et al. were at the forefront of using endoscopic suturing for
closing mucosal defects nearly a decade ago, and its application has since expanded
[14]. Goto et al. propose that endoscopic suturing post-ESD is both feasible and safe,
even demonstrating a decrease in delayed bleeding incidents among patients undergoing
antithrombotic treatment [15].
Despite these advances, there is currently a paucity of comprehensive evidence pertaining
to post-ESD complication rates following application of endoscopic suturing techniques.
A more nuanced understanding of indications for endoscopic suturing, as well as an
assessment of its success rate, is urgently needed to guide clinical practice. This
study aimed to evaluate the feasibility, safety, and effectiveness of endoscopic suturing
for managing post-ESD mucosal defects, including a detailed examination of outcomes
through subgroup analyses based on suturing techniques, antithrombotic drug use, and
lesion location.
Methods
Data sources
To identify pertinent studies, a comprehensive exploration of the databases including
MEDLINE/PubMed, Cochrane Library, Scopus, Web of Science, and Embase was executed.
The investigation was confined to literature published in English from January 1,
2010 to May 1, 2023. Keywords deployed for the search strategy comprised of "Endoscopic
submucosal dissection," "ESD," "suture," "Overstitch," “endoscopic tack-and-suture
device,” and "Endoscopic Hand Suturing". Furthermore, to ensure no relevant research
was missed, the references of each accessed article were meticulously examined to
find any additional related studies that may have been initially omitted.
Study selection
Two independent reviewers sifted through titles and abstracts of the identified articles.
Articles with full-text were gathered for more comprehensive evaluation if they complied
with the defined inclusion criteria. The studies were determined, assessed for applicability,
and included in the meta-analysis according to the following criteria.
Studies were eligible if they included: 1) patients aged ≥18 years who had a single
clinically or histologically confirmed gastrointestinal lesions; 2) provided data
on the role of endoscopic suturing in mitigating post-ESD complications; and 3) were
published between 2010 and 2023. Studies were excluded if they were: 1) case reports;
2) not published in English; 3) not relevant to the objective of the review; 4) did
not report any outcomes of interest; 5) were abstracts; or 6) investigated application
of endoscopic suturing for treatment of perforations or fistulas.
Exclusion of EMR studies
To maintain a consistent study population, we excluded studies involving lesions removed
via EMR. EMR typically involves superficial lesions, whereas ESD is used for deeper
and larger lesions, resulting in different outcomes and complications. Our analysis
specifically targeted the context of ESD, where the depth of resection is a critical
factor.
Discrepancies in the selection process were addressed via discussion and consensus.
This systematic review and meta-analysis adhered to the Reporting Items for Systematic
Reviews and Meta-Analyses (PRISMA) guidelines.
Definitions
Procedure definitions
EHS is a technique employed for closing post-ESD mucosal defects. It can be utilized
in different gastrointestinal tract sections, including the stomach, colon, and rectum.
The technique involves an absorbable barbed suture and a through-the-scope flexible
needle holder, introduced through an overtube or an oblique distal attachment, based
on case-specific requirements. Overstitch refers to a suturing method that involves
affixing an overstitch endoscopic suturing platform to a double-channel therapeutic
gastroscope and advancing it to the ESD site. The method allows suturing in an antegrade
position, beginning from the defect edge most distal to the endoscope insertion site.
The suturing is either continuous or uses separate stitches, depending on the specific
case. The X tack device (endoscopic tack-and-suture device) comprises four surgical
steel tacks linked by a polypropylene thread, which can be deployed without removing
the instrument from the patient. These tacks are embedded into the target tissue near
the defect and then sequentially tightened to secure the structure.
Outcome definitions
Technical success rate was defined as successful placement of the endoscopic suturing
device and complete closure of the mucosal defect. Sustained closure was defined as
the condition in which the mucosal defect remains closed without dehiscence during
follow-up endoscopy. For the purposes of our analysis, sustained closure was assessed
within a standardized follow-up period, ranging from 1 month to 3 months post-ESD,
as reported by the included studies. Delayed bleeding was defined as overt active
bleeding occurring within 30 days post-ESD. Delayed perforation was defined as any
perforation not recognized during the procedure itself but occurring within 30 days
post-ESD.
Procedure time was the duration of the procedure, commencing from the first insertion
of the needle into the mucosa, and ending either with the cutting and freeing of the
remaining suture and needle or with cinch deployment from the endoscopic suturing
platform.
Data extraction and bias assessment
Data on study design, population characteristics, ESD suture-related information,
and outcomes were extracted by one reviewer and verified by a second reviewer. In
case of any discrepancies, a third reviewer was consulted to reach a final decision.
The following data were collected from each study: 1) first author's name; 2) year
of publication; 3) study design; 4) population characteristics including age, sex,
sample size, and lesion type and size, location; and 5) outcomes.
Study quality was assessed using the Newcastle-Ottawa Scale, a tool that evaluates
the quality of non-randomized studies by evaluating three aspects of the study: 1)
selection of study groups; 2) comparability of the groups; and 3) outcome assessment
[16].
Statistical analysis
To assess the effectiveness and safety of ESD suture, a weighted pooled event rate
was calculated for dichotomous outcomes and the weighted pooled mean difference (MD)
for continuous outcomes. For continuous outcomes, specifically procedure times, we
encountered heterogeneity in how these were reported across studies (i.e., some reported
MD, whereas others reported medians and ranges). To standardize our analysis, we converted
medians and ranges to means and standard deviations utilizing a validated algorithm,
which then allowed us to calculate the weighted pooled means for these outcomes. Results
were visually presented in forest plots. Heterogeneity was evaluated using the I2 statistic and the Cochran Q test, with a P < 0.1 in the Cochran Q test suggesting heterogeneity. If the I2 value exceeded 50%, it was interpreted as substantial heterogeneity. Statistical
analyses were performed using Comprehensive Meta-analysis software (version 3.0),
considering a P < 0.05 as statistically significant.
Publication bias
To account for the effect of concealed or unpublished studies, and effectively evaluate
potential publication bias, we implemented comprehensive measures including the utilization
of both funnel plots and the Egger's test. P < 0.10 in the Egger's test would suggest the presence of potential bias.
Sensitivity analysis
To verify result robustness, sensitivity analyses were performed. By sequentially
removing individual studies, we reassessed the data to determine if the overall conclusions
would alter. This allowed us to identify any variability or uncertainty sources in
the results and evaluate their impact on the overall conclusions.
Results
Baseline study characteristics
A total of 426 publications were identified in the initial search, of which 375 were
excluded as duplicates or irrelevant studies. (Supplementary Fig. 1) After applying these exclusion criteria, a total of ten full articles involving
284 patients were included in this meta-analysis [14]
[15]
[17]
[18]
[19]
[20]
[21]
[22]
[23]
[24]. The majority of the included studies were conducted in the United States (n = 7),
and three were conducted in Japan. Four studies were prospective studies and six were
retrospective studies. All included studies performed follow-up endoscopy within a
period ranging from 1 month to 3 months post-procedure to assess for sustained closure
of mucosal defects. This allowed for consistent evaluation of endoscopic suturing
effectiveness over a comparable timeframe. A summary of the included publications
and the baseline characteristics of the participants can be found in [Table 1]. The detailed risk-of-bias assessment is shown in [Table 2].
Table 1 Basic characteristics of included studies.
|
Author
|
Year
|
Country
|
No. of patients
|
No. of lesions
|
Age
|
Female N/%
|
Lesion location
|
No using
antithrombotics
|
Lesion size (mm)
|
Procedure time (min)
|
Sustained
|
Technical success
|
Perforation
|
Bleeding
|
|
Abe S
|
2020
|
Japan
|
11
|
11
|
71 (55–85)
|
N/A
|
Colorectal
|
0
|
35 (25–50)
|
56 (30–120)
|
7
|
8
|
0
|
1
|
|
Akimoto T
|
2021
|
Japan
|
20
|
22
|
74
|
2/10
|
Stomach
|
20
|
12 (2–32)
|
36 (24–60)
|
22
|
22
|
0
|
0
|
|
Ali O
|
2023
|
USA
|
55
|
55
|
67 ± 11
|
22/40
|
Gastroesophageal junction 2, stomach 30 cecum 2 sigmoid 2 rectum 13
|
N/A
|
27.4 (15)
|
N/A
|
N/A
|
55
|
0
|
1
|
|
Callahan Z
|
2019
|
USA
|
5
|
5
|
N/A
|
N/A
|
N/A
|
N/A
|
N/A
|
N/A
|
3
|
5
|
1
|
1
|
|
Farha J
|
2023
|
USA
|
82
|
82
|
65 (55.75–72)
|
37/45.1
|
Colorectal
|
38
|
30 (25–40)
|
10 (6.3–17.3)
|
N/A
|
76
|
0
|
1
|
|
Goto O
|
2020
|
Japan
|
30
|
30
|
73 ± 9.5
|
6/20
|
Stomach
|
15
|
12.4 (7.7)
|
49.5 ± 16.2
|
25
|
29
|
0
|
4
|
|
Han S
|
2020
|
USA
|
31
|
31
|
65.6
|
9/29
|
Gastric 58.1% and rectal 41.9%
|
5
|
27.4 (16.2)
|
13.4 ± 5.9
|
N/A
|
30
|
0
|
0
|
|
Kantsevoy S
|
2014
|
USA
|
12
|
12
|
64.7 ± 11.2
|
7/58.3
|
4 stomach and 8 in colon
|
N/A
|
42.5 (14.8)
|
10 ± 5.8
|
N/A
|
12
|
0
|
0
|
|
Mahmoud T
|
2022
|
USA
|
35
|
35
|
63.6 ± 13.1
|
45/48.4
|
N/A
|
N/A
|
N/A
|
N/A
|
30
|
N/A
|
0
|
1
|
|
Mohapatra S
|
2022
|
USA
|
3
|
3
|
N/A
|
N/A
|
Colorectal
|
N/A
|
N/A
|
N/A
|
N/A
|
3
|
0
|
0
|
Table 2 Quality assessment.
|
Newcastle-Ottawa Quality Assessment Scale for Non-randomized Studies
|
|
Author
|
Selection
|
Comparability
|
Outcome
|
Total
|
|
|
Representativeness of exposed cohort
|
Selection of non-exposed cohort
|
Ascertainment of exposure
|
Demonstration that outcome of interest was not present at start of study
|
Comparability of cohort on the basis of the design or analysis
|
Ascertainment of o0utcome
|
Was follow-up long enough for outcomes to occur
|
Adequacy of follow-up cohorts
|
|
|
Kantsevoy S 2014
|
1
|
0
|
1
|
1
|
0
|
1
|
1
|
1
|
6
|
|
Goto O 2020
|
1
|
0
|
1
|
1
|
0
|
1
|
1
|
1
|
6
|
|
Akimoto T 2021
|
1
|
0
|
1
|
1
|
0
|
1
|
1
|
1
|
6
|
|
Han S 2020
|
1
|
0
|
1
|
1
|
0
|
1
|
1
|
1
|
6
|
|
Abe S 2009
|
1
|
0
|
1
|
1
|
0
|
1
|
1
|
0
|
5
|
|
Farha J 2023
|
1
|
0
|
1
|
1
|
0
|
1
|
1
|
1
|
6
|
|
Mahmoud T 2022
|
1
|
0
|
1
|
1
|
0
|
1
|
1
|
1
|
6
|
|
Ali O 2023
|
1
|
0
|
1
|
1
|
0
|
1
|
1
|
1
|
6
|
|
Callahan Z 2019
|
0
|
0
|
1
|
1
|
0
|
1
|
1
|
1
|
5
|
|
Mohapatra S 2022
|
0
|
0
|
1
|
1
|
0
|
1
|
1
|
1
|
5
|
Primary outcomes
Nine studies, encompassing 251 lesions, presented data on the technical success rate.
The pooled technical success rate was 92.6% (95% CI 0.88–0.96, Cochran Q test P = 0.220, I2 = 25.10%) ([Fig. 1]), The funnel plot's symmetry, coupled with Egger’s test outcome (P = 0.22), denoted no detectable publication bias for this particular estimation. (Supplementary Fig. 2) Subgroup analysis based on different types of endoscopic suturing was performed,
the pooled rate for the EHS was at 88.0% (95% CI 0.73–0.95, Cochran Q test P = 0.059, I2 = 64.7%), the pooled rate for the overstitch was at 97.4% (95% CI 0. 90–0.99, Cochran
Q test P = 0.690, I2 = 0%), and the pooled rate for the X tack was at 92.4% (95% CI 0. 85–0.96, Cochran
Q test P = 0.706, I2 = 0%) (Supplementary Fig. 3).
Fig. 1 Pooled technical success rates of endoscopic suturing post endoscopic submucosal dissection.
The pooled sustained closure rate was 80.7% (95% CI 0.71–0.88, Cochran Q test P = 0.156, I2 = 39.81%) ([Fig. 2]). Funnel plot symmetry, coupled with Egger’s test outcome (P = 0.73), denoted no detectable publication bias for this particular estimation. (Supplementary Fig. 4) Subgroup analysis based on different types of endoscopic suturing was performed,
the pooled rate for the EHS was at 82.4% (95% CI 0.56–0.95, Cochran Q test P = 0.090, I2 = 58.4%) and the pooled rate for the X tack was at 78.6% (95% CI 0. 62–0.89, Cochran
Q test P = 0.154, I2 = 50.74%). Given that just one study provided data on the sustained closure rate
utilizing the overstitch device, a meta-analytical computation of the pooled rate
was precluded (Supplementary Fig. 5).
Fig. 2 Pooled rates for sustained closure of endoscopic suturing post endoscopic submucosal
dissection.
Secondary outcomes
The pooled procedure time was 31.11 minutes (95% CI 16.01–46.21, Cochran Q test P < 0.01, I2 = 99.80 %) ([Fig. 3]). A subgroup analysis was conducted based on method of suturing EHS or non-EHS.
The pooled procedure time for the EHS group was at 51.25 minutes (95% CI 33.86–68.65,
Cochran Q test P < 0.01, I2 = 98.45%). For the non EHS group, the pooled procedure time was 11.12 minutes (95%
CI 8.75–13.48, Cochran Q test P = 0.007, I2 = 79.90%) (Supplementary Fig. 6).
Fig. 3 Pooled procedure time of endoscopic suturing post endoscopic submucosal dissection.
Ten studies reported on the overall delayed perforation rate, with only one event
of perforation noted. Ten studies reported on the overall delayed bleeding rate, with
the pooled event rate at 5.3 % (95% CI 0. 30–0.10, Cochran Q test P = 0.276, I2 = 18.1%), showing low heterogeneity ([Fig. 4]).
Fig. 4 Pooled delayed bleeding rates of endoscopic suturing post endoscopic submucosal dissection.
A subgroup analysis was conducted considering the use of antithrombotic drugs. Five
studies reported data on whether antithrombotic drugs were used. Only three delayed
bleeding events were noted among patients using antithrombotics with a 6.7% event
rate (95% CI 0.02–0.25). Among patients not using antithrombotics, the event rate
was 4.4% (95% CI 0.02–0.12) (Supplementary Fig. 7).
We conducted a subgroup analysis predicated on lesion location, delineating a delayed
bleeding rate of 7.9% (95% CI 0.30–0.10, Cochran Q test P = 0.451, I2 = 0%) for gastric lesions. In contrast, lesions located in the colorectal region
exhibited a pooled delayed bleeding rate of 4.1% (95% CI 0.30–0.10, Cochran Q test
P = 0.707, I2 = 0%) (Supplementary Fig. 8).
Subgroup analysis based on different types of endoscopic suturing was performed, the
pooled rate of delayed bleeding for the EHS was at 10.5% (95% CI 0. 05–0.22, Cochran
Q test P = 0.442, I2 = 0%), the pooled rate of delayed bleeding for the overstitch was at 4.2% (95% CI
0.01–0.14, Cochran Q test P = 0.304, I2 = 17.44%), and the pooled rate of delayed bleeding for the X tack was at 3.4% (95%
CI 0. 01–0.11, Cochran Q test P = 0.572, I2 = 0%) (Supplementary Fig. 9).
Sensitivity analysis
We conducted leave-one-out sensitivity analyses to assess the robustness of our findings.
These analyses involved removing individual studies one by one and reanalyzing the
data, and we found that the results remained consistent regardless of which studies
were included or excluded (Supplementary Fig. 10).
Discussion
Our meta-analysis, the first to explore the feasibility, safety, and efficacy of endoscopic
suturing for managing post-ESD mucosal defects, reveals several noteworthy findings
for future clinical practice. To begin with, the data provide a robust technical success
rate of 92.6%, underscoring the procedural viability of endoscopic suturing. In addition,
we observed a commendable rate of sustained closure following the procedure. Equally
noteworthy was the significantly diminished risk of postoperative complications in
patients undergoing endoscopic suturing with colorectal lesions. Notably, those patients
on antithrombotic therapy manifested markedly decreased rates of delayed bleeding
after endoscopic suturing. Lastly, procedure time for endoscopic suturing was found
to be reasonably efficient.
Our study highlighted the high technical success rate and sustained closure rate as
primary advantages of endoscopic suturing. Previous research reported a 52% mucosal
dehiscence rate with defects closed using hemoclips [12]
[25]. The challenge of closing stomach ESD defects using endoclips, primarily due to
the anatomically thick wall leading to the formation of submucosal spaces, often results
in mucosal dehiscence. Our study, on the other hand, reported an 80.7% sustained closure
rate, signifying a marked improvement over traditional clip-based closure method.
We attribute this improvement to endoscopic suturing techniques, which incorporate
wider bites and sufficient depth, and, if required, an additional stitch at the center
of the mucosal defect [15]
[18]. These findings emphasize the robust suturing capabilities of EHS, overstitch, and
tack suture system.
This study underscores a remarkably low incidence of postprocedural complications
with endoscopic suturing. The proactive closure of larger mucosal defects, despite
inherent technical challenges, could lower the risk of post-ESD AEs [9]
[25]. Animal studies have substantiated that the EHS group shows comparable growth of
new blood vessels and fibroblasts in the submucosal layer - key contributors to gastric
ulcer healing - to that observed in normal submucosal layers [26]. Therefore, it is plausible that proficient endoscopic suturing could hasten the
healing of iatrogenic gastrointestinal mucosal defects post-ESD, and limit complications
among high-risk patients.
Perforation, another notable concern after ESD, has rates of approximately 4.5% after
gastric ESD and 4.8% after colorectal ESD [27]
[28]. Most ESD-related perforations occur intra-procedurally and can be immediately managed
with clip closure. However, a small subset of patients may experience delayed perforations,
which can necessitate emergent surgery. Notably, our study observed only one instance
of delayed perforation after endoscopic suture. In the course of our examination,
it was found that endoscopic suturing was utilized to manage intra-procedural perforations
in two of the studies. Specifically, two instances were reported in the study by Ali
O et al. and three instances in the study by Farha J et al [19]
[21]. In all these cases, the intra-procedural perforations were successfully managed
with endoscopic suturing. This additional finding underscores the potential versatility
and effectiveness of endoscopic suturing not just for prevention of post-procedural
complications, but also for managing complications that may arise during the procedure
itself.
Our subgroup analysis indicated a significant decrease in delayed bleeding rates among
patients receiving anticoagulant or antiplatelet therapy who underwent endoscopic
suturing. The increased prevalence of anticoagulant use among ESD patients necessitates
meticulous management to mitigate the risk of delayed bleeding. While performing ESD
without interrupting anticoagulant therapy is an option for individuals at high risk
of thromboembolic events, it is worth noting that anticoagulant use inherently increases
the risk of delayed bleeding [29]. Specifically, we noted a mere three occurrences, a substantial decrease when compared
with the previous 22.5% to 26.1% incidence rates reported in patients with untreated
mucosal defects on antithrombotic therapy, as indicated in earlier studies [30]
[31]
[32]. Our data suggest that endoscopic suturing could help reduce complications tied
to antithrombotic use in ESD procedures.
Procedure time for endoscopic suturing was 31.11 minutes, potentially extending anesthesia
time and associated risks. However, we observed a decrease in post-procedural AEs,
suggesting that the benefits of endoscopic suturing may outweigh these potential risks.
As endoscopic procedures continue to evolve and mature, we anticipate further improvements
in efficiency.
EHS, Overstitch, and the tack suture system all aim to close mucosal defects following
ESD, although they utilize different tools and procedures. Despite the complexity
of EHS, its powerful suturing capabilities make it a viable option for large defects.
Overstitch, although requiring a specific device and potentially impacting maneuverability
and cost-effectiveness, remains widely used. The X tack device offers a simplified
approach for gastrointestinal defect closure [18]
[21]
[22]. However, balancing simplicity, time-effectiveness, and cost-effectiveness is critical
for these techniques to be widely adopted.
Our subgroup analysis, focused on varying types of endoscopic suturing, yielded key
insights into the technical success rate of each method. The overstitch technique
emerged as particularly successful from a technical success standpoint. Regarding
the sustained closure rate, both the EHS and X tack procedures demonstrated substantial
effectiveness. However, the study was constrained by the lack of available data to
compute a meta-analytical pooled rate of sustained suture for the overstitch device.
An analysis of the delayed bleeding rates associated with different suturing techniques
revealed that both the overstitch and X tack techniques exhibited lower rates than
the EHS, contributing to their favorable safety profiles in relation to post-procedural
bleeding.
Endoscopic suturing in ESD shows promise but poses certain limitations. First, risk
of inadvertently embedding tumor components into the submucosal layer reinforces the
need for astute patient selection [33]. In addition, limited clinical data regarding sustained closure rates beyond postoperative
Day 7 impedes our capacity to evaluate long-term effectiveness of these suturing techniques.
Therefore, long-term follow-up studies are needed to validate these findings in endoscopic
suturing. While we observed a single event of delayed perforation, which matches the
general rate post-ESD, this does not conclusively prove the preventive efficacy of
endoscopic suturing against delayed perforation. This highlights the need for larger-scale
studies to further investigate this potential. Some anatomical regions like the cardia
or pyloric ring may be unsuitable for closure. In such cases, suturing of large mucosal
defects should aim towards the organ's longitudinal direction to minimize post-suturing
stenosis severity. Furthermore, our study does not provide cost-effectiveness data
for endoscopic suturing and further studies are warranted on this area. Selection
of studies for this analysis, six of which were retrospective, introduces the potential
for selective bias. In addition, the analysis lacked direct comparisons among the
overstitch, EHS, and X tack suturing techniques. As such, future research should prioritize
conducting head-to-head comparative studies to better understand the relative merits
and limitations of these methods.
In our analysis, we converted medians and ranges to means and standard deviations
using a validated algorithm to harmonize the available estimates. However, this method
assumes a normal distribution, which may not accurately reflect the skewness of the
data, particularly for procedure time. This assumption may introduce some bias in
the results. Future studies should consider reporting both mean and median values
to better represent the data distribution and ensure a more robust statistical analysis.
We acknowledge the inclusion of studies with incomplete datasets on lesion size and
location, notably the Callahan et al. study. This decision was made to encompass a
broad spectrum of available evidence on endoscopic suturing post-ESD. However, we
recommend interpreting the pooled results with caution, considering these limitations.
Future research should aim for more detailed reporting to enhance the comparability
and interpretation of findings across studies.
Conclusions
In conclusion, endoscopic suturing offers a promising solution for managing post-ESD
mucosal defects in patients with antithrombotic therapy. Despite challenges and limitations
related to technique, lesion location, and cost, techniques such as EHS, overstitch,
tack suturing system hold potential for enhancing patient outcomes. The findings call
for further large-scale, prospective studies to validate these outcomes and focus
on developing standardized methodologies.
