title: New flexible endoscopic full-thickness suturing device: a triple-arm-bar suturing system.
abstract: OBJECTIVE
  A reliable full-thickness suturing device is necessary for pure natural orifice transluminal endoscopic surgery (NOTES). The present study focused on assessing the reliability of a new suturing device.
  
  
  METHODS
  A total of 60 single sutures were tested to close 5-cm incisions in 8-cm square pieces of resected swine stomach. Each incision was sutured by an over-the-scope clip (OTSC; n = 20), a single hand-sewn stitch (n = 20), or a single triple-arm-bar suturing system (TBSS) stitch. The maximum pulling force durability (MPD) of each suture was tested. To assess the reliability of the TBSS for endoscopic full-thickness resection (EFTR), 60 EFTRs of 50 mm diameter were performed on excised swine stomachs. After EFTR, full-thickness sutures were made using 3-stitch OTSCs (n = 20), 10-stitch hand-sewn sutures (n = 20), or 10-stitch TBSS sutures (n = 20). Outcomes were the MPD test for both single stitch and multiple stitch applications and the suturing time for single-stitch sutures.
  
  
  RESULTS
  In the single-stitch MPD tests, there were significant differences between OTSCs and hand-sewn sutures (P = 0.0002) and between OTSCs and TBSS sutures (P = 0.0001), but no significant difference between hand-sewn and TBSS sutures. The multiple-stitch sutures revealed significant differences between OTSCs and hand-sewn sutures (P = 0.0039), and between OTSCs and TBSS sutures (P = 0.013). There was no significant difference between hand-sewn and TBSS sutures. There were significant differences in suture times between OTSC, hand-sewn sutures, and TBSS sutures (P < 0.05).
  
  
  CONCLUSIONS
  Both single-stitch and multiple-stitch sutures using TBSS have similar strength to hand-sewn sutures. TBSS is a reliable suturing device.
authors.affiliation: Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Kagawa 761-0793, Japan. hiro4884@med.kagawa-u.ac.jp
authors.forename: H
authors.initials: H
authors.lastname: Mori
authors.forename: H
authors.initials: H
authors.lastname: Kobara
authors.forename: K
authors.initials: K
authors.lastname: Rafiq
authors.forename: N
authors.initials: N
authors.lastname: Nishiyama
authors.forename: S
authors.initials: S
authors.lastname: Fujihara
authors.forename: M
authors.initials: M
authors.lastname: Kobayashi
authors.forename: M
authors.initials: M
authors.lastname: Oryu
authors.forename: M
authors.initials: M
authors.lastname: Fujiwara
authors.forename: Y
authors.initials: Y
authors.lastname: Suzuki
authors.forename: T
authors.initials: T
authors.lastname: Masaki
mesh_terms: D000818:Animals; D057605:Natural Orifice Endoscopic Surgery / Q000295:instrumentation*; D013270:Stomach / Q000601:surgery*; D013536:Suture Techniques / Q000295:instrumentation*; D013552:Swine; D013718:Tensile Strength