Marking can improve defect closure in endoscopic suturing systems

The emergence of endoscopic suturing systems (ESS) provides a nonsurgical approach to rescuing perforations during endoscopic resection of gastric gastrointestinal tumors [1] [2] [3]. OverStitch Sx (Boston Scientific, Marlborough, Massachusetts, USA) can be applied to most single-channel endoscopes at the cost of hindering maneuverability. Furthermore, achieving complete full-thickness poses a challenge owing to the anatomic complexities and the obscured visibility of the muscle defect beneath the flap. Endoscopic techniques of ESS remain unfamiliar to most endoscopists. The marking technique is occasionally employed in endoscopic sleeve gastroplasty but has seldom been mentioned in the context of defect closure.

We present the management of a 72-year-old patient undergoing submucosal tunneling endoscopic resection (STER) for a 2-cm gastrointestinal tumor located at the anterior wall of the antrum. After STER, the resulting full-thickness defect was closed using six clips. The patient experienced delayed perforation 3 hours post-procedure, verified with esophagogastroduodenoscopy ([Fig. 1], [Video 1]). Subsequently, all clips were removed and peritoneal cleansing was performed. We rescued the perforation using the OverStitch Sx device, with the aim of achieving full-thickness approximation.

Fig. 1 Rupture of the previously clip-closed defect from submucosal tunneling endoscopic resection was noted.

Marking can improve defect closure in endoscopic suturing systems.Video 1

Defect closure presented several challenges. First, targeting the muscle layer was difficult because it was covered by the mucosal flap ([Fig. 2]). Second, the hindered control and partial loss of vision caused by the suturing device further exacerbated the situation. Prior to suturing, we used Dual J (Olympus, Tokyo, Japan) to mark the areas for stitches ([Fig. 3], [Fig. 4]). Subsequently, we successfully applied four stitches using OverStitch Sx under the guidance of the marking ([Fig. 5]). The patient experienced a smooth recovery, progressing to a clear liquid diet within 4 days, and was discharged 6 days post-procedure.

Fig. 2 The full-thickness defect was difficult to approximate because it was covered by the mucosal flap.

Fig. 3 Marking was performed to facilitate seamless stitching during OverStitch Sx suturing (Boston Scientific, Marlborough, Massachusetts, USA).

Fig. 4 Stitching was performed smoothly following the marking guidance.

Fig. 5 Finally, full-thickness approximation was achieved.

We demonstrate the effectiveness of ESS in managing delayed gastric perforation, which traditionally necessitates surgical intervention. The marking technique can significantly improve the effectiveness of ESS for defect closure.

Endoscopy_UCTN_Code_CPL_1AH_2AZ_3AZ

• References

• 1 Paspatis GA, Arvanitakis M, Dumonceau JM. et al. Diagnosis and management of iatrogenic endoscopic perforations: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement – Update 2020. Endoscopy 2020; 52: 792-810
• 2 Maselli R, Palma R, Traina M. et al. Endoscopic suturing for GI applications: initial results from a prospective multicenter European registry. Gastrointest Endosc 2022; 96: 780-786
• 3 Chou CK, Chen CC, Chen SS. et al. Snare traction and endoscopic suturing can improve endoscopic management of gastrointestinal stromal tumors at the gastric greater curvature. Endoscopy 2023; 55: E216-E217