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COMPARING RAT-TOOTH FORCEPS TO A TISSUE HELIX FOR TISSUE ACQUISITION DURING ENDOSCOPIC SUTURING
Daniel Szvarca
*, Trent Walradt, Christopher C. Thompson
Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA
BACKGROUNDEndoscopic suturing is a versatile technique with numerous applications. It is often crucial to place full-thickness stitches, especially when closing perforations or performing bariatric procedures. This is traditionally accomplished by using a tissue helix. However, the helix can become stuck in tissue or adjacent structures, occasionally leading to bleeding and tissue damage. Less commonly, rat-tooth forceps are used during endoscopic suturing. This study aims to evaluate the comparative efficacy and safety of these two tissue acquisition devices for endoscopic suturing.
METHODSWe tested the performance of two tissue acquisition devices: a tissue helix and rat-tooth forceps
(Fig 1). Using an ex-vivo, porcine gastric model with a constant insufflation pressure of 10 mmHg, an endoscopic suturing device was used to perform a running suture with 8 stitches in the fundus with both acquisition devices. We assessed the rate of full-thickness stitches, inadvertent tissue release, delayed tissue release, transmural device penetration, and the National Aeronautics and Space Administration Task Load Index (NASA-TLX), a validated survey of physical and mental workload. The tensile strength required to pull each device out of tissue after standardized acquisition was also measured using a digital force gauge.
RESULTS Five running sutures were performed with each device for a total of 10 trials. Full-thickness acquisition was accomplished in 40/40 stitches using the rat-tooth forceps compared to 39/40 stitches using the tissue helix (P=1.0)
(Fig 2). The tissue helix had a greater rate of failed tissue acquisition (6/40 vs 1/40; P=0.11), delayed tissue release (8/40 vs 1/40; P=0.03), and transmural device penetration (6/40 vs 0/40; P=0.03), compared to the rat-tooth forceps. NASA-TLX scores showed more physical and mental workload for endoscopists when using the rat-tooth forceps (52.0 ± 14.1 vs 32.2 ± 8.1; P=0.03) while scores were higher for the technician when using the tissue helix (61.8 ± 12.5 vs 28.0 ± 7.3; P=0.002). Finally, in assessing potential for inadvertent loss of tissue acquisition, the tension required to pull the rat-tooth off acquired tissue was greater than that of the tissue helix (59.6 N ± 24.3 vs 25.9 N ± 2.2; P=0.04).
CONCLUSIONRat-tooth forceps are as effective as a tissue helix for full-thickness tissue acquisition during endoscopic suturing, with the added potential of reducing tissue damage and minimizing extra-luminal complications. Additionally, the tensile force required to remove rat-tooth forceps from tissue is greater than that of the tissue helix, likely resulting in fewer instances of failed tissue acquisition. This ex-vivo study suggests rat-tooth forceps are a reliable, effective, and safe tool for endoscopic suturing, emphasizing the need for further clinical research to confirm these findings.
Figure 1. Endoscopic suturing with tissue acquisition devices: A) Tissue helix, B) Rat-tooth forceps, C) Example of full-thickness stitches in porcine stomach, D) Transmural tissue helix penetration
Figure 2. Comparing rat-tooth forceps and tissue helix for use during endoscopic suturing
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