title: Endoscopic suturing is superior to endoclips for closure of gastrotomy after natural orifices translumenal endoscopic surgery (NOTES): an ex vivo study.
abstract: BACKGROUND
  Closure of gastrotomy remains a major barrier to clinical application of NOTES. Full-thickness closure of gastrotomy using endoscopic suturing device is presumed to be safer than that by endoclips. We evaluated the safety and feasibility of closing gastrotomy by Eagle Claw VIII, endoclips, and surgical suturing.
  
  
  METHODS
  Fifty-one ex vivo porcine stomach models were included with 17 closures per arm. A 2-cm linear incision was created at the gastric body using scalpel externally. The time for gastrotomy closure, pneumatic bursting pressure, site of air leakage and number of suturing, or clips used were recorded. In addition, the technical difficulties of closure using Eagle Claw VIII and endoclips were assessed by a quantitative scale.
  
  
  RESULTS
  All gastrotomies were successfully closed without leakage upon full gaseous distension. Closure time of Eagle Claw VIII was significantly longer than that of endoclips and surgical suturing. The median pneumatic bursting pressures were 56 (range 35-110) mmHg for Eagle Claw VIII, 19 (range 9-65) mmHg for endoclips, and 78 (range 63-110) mmHg for surgical suturing. The bursting pressures for surgical suturing and Eagle Claw VIII were significantly higher than that of endoclips (P < 0.001 for both surgical suturing vs. endoclips and Eagle Claw VIII vs. endoclips). The median scores for technical difficulties was not significantly different between endoclips and Eagle Claw VIII [9.5 (range 7-10) vs. 10 (range 8.5-10); P = 0.073].
  
  
  CONCLUSIONS
  The results indicated that closure of gastrotomy by Eagle Claw VIII could withstand higher endoluminal pneumatic bursting pressure than endoclips. The performance of endoscopic suturing with Eagle Claw is still difficult, and further refinement of the endoscopic suturing device is necessary for clinical application.
authors.affiliation: Department of Surgery, CUHK Jockey Club Minimally Invasive Surgical Skills Center, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32 Ngan Shing Street, Shatin, NT, Hong Kong, liuliu@surgery.cuhk.edu.hk.
authors.forename: Liu
authors.initials: L
authors.lastname: Liu
authors.forename: Philip Wai Yan
authors.initials: PW
authors.lastname: Chiu
authors.forename: Anthony Yuen Bun
authors.initials: AY
authors.lastname: Teoh
authors.forename: Candice Chuen Hing
authors.initials: CC
authors.lastname: Lam
authors.forename: Enders Kwok Wai
authors.initials: EK
authors.lastname: Ng
authors.forename: James Yun Wong
authors.initials: JY
authors.lastname: Lau
mesh_terms: D000818:Animals; D004195:Disease Models, Animal; D004867:Equipment Design; D005743:Gastrectomy / Q000379:methods*; D005773:Gastroscopy / Q000379:methods*; D009055:Mouth; D057605:Natural Orifice Endoscopic Surgery / Q000379:methods*; D013270:Stomach / Q000601:surgery*; D013272:Stomach Diseases / Q000601:surgery*; D013536:Suture Techniques / Q000295:instrumentation*; D013537:Sutures; D013552:Swine