Feasibility Study on Endoscopic Suture with the Combination of a Distal Attachment and a Rotatable Clip for Complications of Endoscopic Resection in the Large Intestine

• Introduction
• Patients and Methods
• Results
• Discussion
• Acknowledgement
• References

Background and Study Aims: Endoscopic resection has been more frequently performed for increasingly larger intramucosal tumors of the large intestine in recent years. It is reasonable to expect that the larger the resected mucosal surface, the greater is the likelihood of complications such as bleeding or perforation. The aim of this study was to explore the feasibility of endoscopic suture with a distal attachment and a rotatable clip-fixing device for complications of endoscopic resection in the large intestine.

Patients and Methods: The study population consisted of 15 patients who underwent endoscopic clipping therapy following endoscopic resection for intramucosal tumors of the large intestine. With a distal attachment fitted to the distal end of the endoscope, the optimal position for clipping was ensured by pressing the intestinal wall and deflating the intraluminal air little by little. With a rotatable clip-fixing device, the resection site was endoscopically sutured clip by clip.

Results: Tumors were of the laterally spreading tumor type in six patients, small sessile polyps in three, and pedunculated polyps in six. The complications consisted of bleeding in 12 patients, overt perforation in one, and latent perforation in two; 14 of the 15 patients underwent successful suturing by this method. The number of clips used ranged from two to seven (mean 4.4). No patients had further complications after the treatment.

Conclusion: We conclude that endoscopic suture with the combination of a distal attachment and a rotatable clip-fixing device is very useful for complications of endoscopic resection in the large intestine.

Introduction

With the widespread use of colonsocopy and the development of new colonoscopic techniques, endoscopic resection is increasingly being performed on ever larger intramucosal tumors of the large intestine. It is reasonable to expect that the larger the resected mucosal surface, the greater is the likelihood of complications such as bleeding or perforation. Satisfactory results have been reported using endoscopic suture with a rotatable clip-fixing device [1]; however, we have experienced difficulty with the actual procedure in the uneven lumen of the large intestine. The distal attachment (Figure [1]) is a transparent plastic cap developed for enabling endoscopic mucosal resection in the digestive tract [2]. We have previously reported the usefulness of the distal attachment in the endoscopic resection of laterally spreading tumors (LSTs) of the large intestine [3]. The aim of this study was to explore the feasibility of endoscopic suture with a distal attachment and a rotatable clip-fixing device for complications of endoscopic resection in the large intestine.

Patients and Methods

The study population consisted of 15 patients who underwent endoscopic suture for complications associated with endoscopic resection for intramucosal tumors of the large intestine encountered from August 1997 to August 1999. An LST, which nearly corresponds to the term “large sessile polyp” used in Western countries, is a lesion 10 mm or greater in diameter that is low in height and grows superficially [4]. A “small sessile polyp” means a sessile polyp under 10 mm in diameter. The diameter of the tumors was measured on radiographic films or on the resected specimens.

The complications included bleeding, perforation, and latent perforation. Latent perforation is the condition in which the endoscopist feels apprehensive of causing perforation because the resection site has turned markedly white with some rigidity owing to excessive coagulation or because the inner circular muscular layer underlying the resection site has torn.

With a distal attachment (MH-466, MH-483, Olympus Optical, Tokyo, Japan) fitted to the distal end of the endoscope (CF-2301, CF-200HI, Olympus), endoscopic suture was performed with a rotatable clip-fixing device (HX-5QR-1, Olympus). The clips used in this study were MD-59 and MH-858 (Olympus). The procedure is shown in Figure [2]. First, the resection site was carefully observed and the optimal position for clipping was ensured by pressing the intestinal wall with the cap. Second, intraluminal air was deflated little by little so that the wound could be narrowed. Third, a clip was rotated so as to perpendicularly cross over the edges of the wound and was fixed tightly. By repetition of this manipulation, the resection site was completely sutured.

Results

The tumors were LSTs in six patients, small sessile polyps in three, and pedunculated polyps in six. Pathological investigation showed hyperplasia in one patient, adenoma in 11, and mucosal carcinoma in three. The complications were bleeding in 12 patients, overt perforation in one, and latent perforation in two. Of the 15 patients, 14 were successfully sutured using this method (Figure [3]). The number of clips used ranged from two to seven (mean 4.4). No patients had any further complications after the treatment.

Discussion

The incidence of complications accompanying endoscopic colonic polypectomy ranges from 0.2 % to 1.86 % for hemorrhage and from 0.2 % to 0.96 % for perforation [5] [6] [7] [8] [9] . Major hemorrhage tends to occur during polypectomies of over 2 cm [10]. Thus, it is assumed that the increased use of endoscopic mucosal resection (EMR), which brings about a large area of mucosal defect, adds to the risk of these complications.

Endoscopic suture using clips on the mucosal defect has been reported along with the increased use of EMR in the upper and the lower digestive tract [1] [11] . The development of a rotatable clip-fixing device, which facilitates more accurate clipping, has made a major contribution to improved handling in the clipping procedure [1], but there are still a few problems that the rotatable function alone cannot solve. First, as the inner surface of the large intestine is uneven, consisting of the haustra and semilunar folds, when the scope runs parallel to the surface of the resection site, clipping is difficult. Second, the larger the resection site, the harder it is to close the wound with clips.

The rationale in using the cap lies mainly in overcoming these two problems. First, by promptly pressing the cap to the intestinal wall, which we call “pressing”, we enable the scope to perpendicularly face the wound. Maintaining this position is an important factor in accomplishing accurate clipping, because it enables the easiest and strongest clipping. Next, when the resected area is large, narrowing the wound is another key point, and to achieve this, it is important to make use of the suction function. By gradually aspirating the intraluminal air with the cap, while retaining the field of vision, we are able to narrow and transform into an approximate straight line the wound which is being aspirated into the cap. Then it is fixed by the clips which are rotated to intersect the linear wound.

We achieved a successful outcome in one case of overt perforation, which has been previously published as a case report [12]. Although we did not notice the significance of the distal attachment at that time, we are now convinced that the successful endoscopic suture while under heavy pressure to avoid an iatrogenic complication was not only due to the rotatable clip but also to the distal attachment. We performed prophylactic endoscopic suture in two patients who were diagnosed as having latent perforation. It would be desirable in terms of decreasing the incidence of complications and the advancement of wound healing if prophylactic endoscopic suture was routinely performed on all patients with endoscopic resection. Considering the low rate of the incidence of complictions in colonic polypectomy [5] [6] [7] [8] [9] , however, this may not be practicable in terms of cost, time, and labor. We believe it to be imperative that prophylactic endoscopic suture is attempted at least in patients with latent perforation to avoid the iatrogenic complications of perforation and peritonitis.

We consider this transparent cap, which is a simple device, to be a very valuable tool in that it can control the position relationship between the scope and the wound by “pressing” and can provide the space to carry out the clipping procedure while retaining the field of vision. In conclusion, endoscopic suture with the combination of a distal attachment and a rotatable clip-fixing device was found to be very useful for complications of endoscopic resection in the large intestine.

Acknowledgement

The authors thank Mr John Cole for proofreading the manuscript.

References

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Hiroaki Yoshikane, M.D.

Dept. of Internal Medicine Handa City Hospital

2-29 Toyo-cho Handa Aich 475 Japan

Fax: Fax:+ 81-569-24-3253

Email: E-mail:winwin@gld.mmtr.or.jp

References

• 1 Hachisu T, Yamada H, Satoh S, et al. Endoscopic clipping with a new rotatable clip-device and a long clip.  Dig Endosc. 1996;  8 127-133
  PubMedSearch in Google Scholar
• 2 Inoue H, Takeshita K, Hori H, et al. Endoscopic mucosal resection with a cap-fitted panendoscope for esophagus, stomach, and colon mucosal lesions.  Gastrointest Endosc. 1993;  39 58-62
  CrossrefPubMedSearch in Google Scholar
• 3 Yoshikane H, Hidano H, Sakakibara A, et al. Endoscopic resection of laterally spreading tumors of the large intestine using a distal attachment.  Endoscopy. 1999;  31 426-430
  Thieme ConnectPubMedSearch in Google Scholar
• 4 Kudo S. Endoscopic mucosal resection of flat and depressed types of early colorectal cancer.  Endoscopy. 1993;  25 455-461
  Thieme ConnectPubMedSearch in Google Scholar
• 5 Wolff W I, Shinya H. A new approach to colonic polyps.  Ann Surg. 1973;  178 367-378
  PubMedSearch in Google Scholar
• 6 Berci G, Panish J F, Schapiro M, et al. Complications of colonoscopy and polypectomy. Report of the Southern California Society for Gastrointestinal Endoscopy.  Gastroenterology. 1974;  67 584-585
  PubMedSearch in Google Scholar
• 7 Geenan J E, Schmitt Jr M G, Hogan W J. Complication of colonoscopy (abstract).  Gastroenterology. 1974;  66 812
  PubMedSearch in Google Scholar
• 8 Smith L E, Nivatvongs S. Complication in colonoscopy.  Dis Colon Rectum. 1975;  18 214-220
  PubMedSearch in Google Scholar
• 9 Silvis S E, Nebel O, Rogers G, et al. Endoscopic complications. Results of the 1974 American Society for Gastrointestinal Endoscopy survey.  J A M A. 1976;  235 928-930
  CrossrefPubMedSearch in Google Scholar
• 10 Macrae F A, Tan K G, Williams C B. Towards safer colonoscopy: a report on the complications of 5000 diagnostic or therapeutic colonoscopies.  Gut. 1983;  24 376-383
  CrossrefPubMedSearch in Google Scholar
• 11 Hikishima K, Mori A, Tsunamura Y, et al. Closure of mucosal defect with metal clips after endoscopic mucosal resection designed for the cases of early gastric carcinoma. (In Japanese with English abstract).  Gastroenterol Endosc. 1994;  36 1792-1801
  PubMedSearch in Google Scholar
• 12 Yoshikane H, Hidano H, Sakakibara A, et al. Endoscopic repair by clipping of iatrogenic colonic perforation.  Gastrointest Endosc. 1997;  46 464-466
  CrossrefPubMedSearch in Google Scholar

Hiroaki Yoshikane, M.D.

Dept. of Internal Medicine Handa City Hospital

2-29 Toyo-cho Handa Aich 475 Japan

Fax: Fax:+ 81-569-24-3253

Email: E-mail:winwin@gld.mmtr.or.jp