Randomized Controlled Trial of Over-the-Scope Versus Through-the-Scope Suturing of ESD Defects

Randomized Controlled Trial of Over-the-Scope Versus Through-the-Scope Suturing of ESD Defects

Douglas K. Rex, MD, MASGE, reviewing Agnihotri A, et al. Gastrointest Endosc 2023 Aug 1.

Over-the-scope suturing (OTSS) requires a double-channel gastroscope, and closure of defects in the right side of the colon may require an overtube. Through-the-scope suturing (TTSS) can be performed using a single-channel instrument, typically the same endoscope used to perform the resection.

This was a single-center randomized controlled trial designed to examine the relative efficiency of OTSS versus TTSS. Twenty patients were randomized to each arm after endoscopic submucosal dissection. In both arms, about one-fifth of patients had gastric lesions, one-third had proximal colon lesions, and half had lesions in the distal colon.

In both the per-protocol and intention-to-treat analyses, the mean closure time was several minutes shorter with OTSS. When setup time was considered, mean closure time was still shorter with OTSS. Overall successful closure was achieved in 85% of patients with OTSS and 90% with TTSS. In the right side of the colon, OTSS achieved closure in 2 of 4 cases, while all 6 with TTSS were successful.

TTSS was less expensive with lesions smaller than 35 mm because only one TTSS system was required. Overall, 9 of 18 cases required more than one TTSS system for closure.

Two cases of delayed bleeds occurred, both in the OTSS arm.

Douglas K. Rex, MD, FASGE


Some experts feel strongly that TTSS is inherently less effective than OTSS because it does not create a full-thickness closure. Available data suggest bleeding rates after TTSS are low. These data on efficiency suggest the clearest benefit of TTSS is for right-sided colon lesions when no overtube is used.

Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.


Agnihotri A, Mitsuhashi S, Holmes I, et al. A randomized trial comparing gastric and colorectal endoscopic submucosal dissection defect closure using novel through the scope suturing system with over-the-scope suturing system. Gastrointest Endosc 2023 Aug 1. (Epub ahead of print) (https://doi.org/10.1016/j.gie.2023.07.046)

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