Mucosal colonic defect post EMR or ESD: to close or not?

Abstract

The advent of endoscopic clips has resulted in a new era in colonic endoscopic resection. Clips pro-vide an easily applicable, durable and robust method of closure of resection defects [1]. This has allowed endoscopists to push the boundaries of techniques with greater control over the risks of perforation and bleeding. Adverse events (AEs) that once may have required surgical salvage can now be managed safely, and provided that a pa-tient's clinical disposition post-endoscopy is unal-tered, they are now regarded as procedural events. In the case of per-oral endoscopic myotomy (POEM) and natural orifice transluminal endo-scopic surgery (NOTES), clips allow the closure of an iatrogenic full-thickness injury, a concept which was once anathema to endoscopists. There is no question that application of clips is effective in the setting of perforation, mural injury and ac-tive bleeding. The ubiquitous availability and ease of use of these devices, however, now may have resulted in the pendulum swinging towards their use in settings where there may be marginal ben-efit. Endoscopists may use clips to guarantee their peace of mind, rather than according to any evi-dence-based cost/benefit strategy. In this edition of Endoscopy International Open, Akimoto et al. describe a novel technique for clo-sure of large colonic endoscopic submucosal dis-section (ESD) defects. Repositionable clips are used to grasp the mucosa at the distal defect edge, then drag this into apposition with the prox-imal defect edge. The clip is then gently opened, allowing capture of the proximal margin while holding the distal margin with one clip arm. The clip is then deployed, holding the defect together so that standard clips may be adjacently applied to the now more closely apposed mucosal edges. The study was a single-center, retrospective co-hort of 32 patients undergoing colonic ESD. Clip closure was attempted in 19 patients. Closure was not attempted for rectal lesions (n = 9) due to the relative fixation of the colon wall in the pelvis, and was also not attempted where lesions in-volved the ileocecal valve (n = 3) or had evidence of submucosal invasion (n = 1). Complete closure was effected in 18 /19 patients with 1 failure due to a mobile sigmoid colon. Mean defect size was 40.2 ± 12.0 mm and it took a mean 10.7 ± 7.2 min-utes to complete the clipping procedure. No ad-verse events were reported in the clipped group. The authors did not report the frequency of AEs in the unclipped group. The defects do not appear to have been objectively examined prior to clipping to determine if there had been deep injury or per-foration. The authors rightly point out that this is a demonstration of concept study, and that it is inadequately powered to determine any effect on adverse outcomes. In essence, Akimoto et al. have shown us a neat technique with a specialized clip to close large ESD defects. Many who use clips will be familiar with a version of this method using standard clips whereby one arm of an open clip is embedded in a defect edge and dragged by traction to a more fa-vorable position, however, the Akimoto technique allows greater tension and control to be applied. Alternative methods of closure including endo-scopic suturing or over-the-scope clips have been described, however, they typically are cumber-some or technically challenging, and require withdrawal and reinsertion of the endoscope. The wider question surrounding these technical tricks is whether we should be closing these re-section defects at all. The benefits of partial or complete closure of EMR or ESD defects are far from certain. There are well-established data showing that the rate of clinically significant delayed bleeding is 6 % to 7 % following EMR and 1 % to 2 % following ESD [2, 3]. Perfora-tion is a rare event for either procedure, occurring in 0.9 % to 2.0 % following EMR and 4 % to 6 % fol-lowing ESD [3, 4]. Delayed perforation is even less common, seen in only 0.2 % following EMR [5[. With low event rates, studies examining the effi-Burgess Nicholas G et al. Mucosal colonic defect post EMR or ESD … Endoscopy International Open 2016; 04: E1073–E1074