Comment to E-Video by Gupta et al.

We read with great interest the E-Video article by Gupta et al. showing the rescue of an impacted endoscopic suturing device during endoscopic sleeve gastroplasty [1].

As shown in a previous article by our group, the misalignment between the needle driver and the anchor exchange, with failure of the opening function, is a challenging situation that may occur during a standard procedure [2] ([Fig. 1]). The first rule to follow to avoid this is to keep the anchor exchange in the channel (out of the view field). However, when this happens while passing the needle through the tissue, the suturing device and the stomach become strongly interlocked. We suggest an easier and safer rescue method for releasing an impacted suturing system and thus avoiding emergency surgery.

Fig. 1 Misalignment of endoscopic suturing device.

A grasping forceps is inserted into the helix channel of the device and is used to push against the needle driver with the impacted gastric tissue. The maneuver should be performed carefully by firm but controlled pressure. The forceps induces the opening of the needle driver and the release of the gastric wall ([Video 1]). Then, an endoscopic scissor or argon plasma coagulation can be used to cut the thread, thus completely freeing the suturing system from the stomach. The release of the tissue without the use of a needle knife and electrocautery makes the procedure faster and safer for the patient. We also believe that the use of the needle knife increases the risk of bleeding and perforation and must be performed only by expert hands.

Video 1 Technique for releasing an impacted suturing system.

Finally, as prevention is better than cure, we strongly recommend that full operator concentration is maintained, the procedural steps are followed, and the anchor exchange is retained in the channel when closing the needle driver in order to avoid misalignment.

Publication History

Article published online:
29 March 2023

• References

• 1 Gupta S, Maher A, Selvanathan P. et al. Rescuing the impacted endoscopic suturing device during endoscopic sleeve gastroplasty. Endoscopy 2022; DOI: 10.1055/a-1858-4499.
• 2 Bove V, Gallo C, Pontecorvi V. et al. Common and uncommon problems during endoscopic suturing with Apollo Overstitch: tips and tricks for troubleshooting. TIGE 2021; 23: 220-225