Aims Recently the technique of freehand suturing in GI endoscopy evolved by developments
such as knotless barbed wire sutures and needle manipulators. Beside closing of mucosal
or complete wall defects of the GI tract one of our first thoughts was the use of
the suture string to apply tension to the mucosa while doing ESD or other submucosal
preparation. In the following we present the technique of freehand suture traction
during ESD in an ex vivo porcine model.
Methods First, some electrocautery marks were applied to the mucosal surface to indicate
the lesion. Afterwards using a hybrid knife (ERBE Elektomedizin Tübingen Germany)
we gained access to the submucosal space and injected dyed saline solution. After
preparing two entry points to the submucosal space at the proximal and distal part
of the lesion we performed a suturing of the approximal part of the lesion using a
barbed wire (V-Loc 180, ½ circle taper end needle 3-0, Covidien). Steering of the
needle was performed using a distal attachment cap (MTW Endoskopie, Wesel, Germany)
and a needle holder (Sutuart, Olympus, Hamburg, Germany). This barbed wire was then
again sutured to the opposing site of the gastric lumen and carefully tensed until
the mucosa at the lesion side performed a tenting thus opening the submucosal space
for further preparation. Preparation was performed using the hybrid knife using precise
sect and spray coagulation mode while each mucosal plane was cut after preparation
of adjacent submucosa leading to a peel away of the growing resection flap using endo
cut mode. In case the suture string lost the tension the barbed wire was carefully
tensed again by just pulling the filament a little bit more through the suture tract
thus, guaranteeing tenting and traction of the mucosal flap.
Results This is the first report of using a barbed wire freehand suturing to apply traction
during ESD. This technique is easy to perform and has low costs.
Conclusions Advantages towards other techniques for applying traction is that the amount of tension
can be adapted by just pulling the filament more through the mucosal surface. Another
advantage is that the specimen is easy to restore from the body after finishing the
resection and that it is clearly marked by the filament. This may help for better
histopathologic orientation, too.
