Endoscopic Treatment of Various Gastrointestinal Tract Defects with an Over-the-Scope Clip: Case Series from a Tertiary Referral Hospital

Experimental Evaluation of the Optimal Suture Pattern With a Flexible Endoscopic Suturing System

BACKGROUND

The ability to perform reliable, secure endoluminal closure of the gastrointestinal tract wall, is a prerequisite to support the progress of the emerging field of endoluminal surgery. Along with advanced clipping systems, flexible endoscopic suturing devices are commercially available. Current systems can replicate traditional surgical suturing patterns in the endoluminal environment. The aim of this study was to evaluate the optimal endoluminal suturing technique using a flexible endoscopic suturing device.

MATERIALS AND METHODS

Procedures were performed on bench-top simulators containing 20 explanted porcine stomachs. A standardized 3-cm full-thickness incision was created on the anterior wall of each stomach using monopolar cautery. The gastrotomy was closed endoscopically using an over-the-scope suturing device (OverStitch, Apollo Endosurgery; Austin, TX). Three different techniques were used: single stitches, figure-of-8 pattern, and running suture. Material consumption and operation time were recorded and bursting pressure measurement of the closure was performed.

RESULTS

No statistically significant differences were identified in suturing time. Suturing time (minutes) was slightly shorter with the figure-of-8 technique (41.14 ± 4.6) versus interrupted (45.75 ± 1.1) versus continuous (51.44 ± 10.0), but the difference was not statistically significant. The number of sutures required was greater in the interrupted group. No significant difference was found in the burst pressure (mm Hg): figure-of-8 (45.85 ± 26.2) versus interrupted (30.5 ± 22.89) versus continuous (32.0 ± 26.5). In the figure-of-8 group, 85.5% of cases were leakproof above 30 mm Hg, while in the other groups only 50% of cases were so.

CONCLUSION

A figure-of-8 suturing pattern seems to be the preferable suturing technique with the endoscopic suturing device.

Endoscopic Closure for Full-Thickness Gastrointestinal Defects: Available Applications and Emerging Innovations

Full-thickness gastrointestinal defects such as perforation, anastomotic leak, and fistula are severe conditions caused by various types of pathologies. They are more likely to require intensive care and a long hospital stay and have high rates of morbidity and mortality. After intentional full-thickness opening of hollow organs for natural orifice transluminal endoscopic surgery, safe and secure closure is urgently required. The currently available advanced endoscopic closing techniques have a major role in the treatment of full-thickness gastrointestinal defects. Appropriate usage of these techniques requires taking into account their advantages and limitations during practical application. We reviewed the available endoscopic modalities, including endoscopic clips, stents, vacuum-assisted closure, gap filling, and suturing devices, discussed their advantages and limitations when treating full-thickness gastrointestinal defects, and explored emerging innovations, including a novel endoluminal surgical platform for versatile suturing and a cell-laden scaffold for effective gap filling. Although these emerging technologies still require further pre-clinical and clinical trials to assess their feasibility and efficacy, the available modalities may be replaced and refined by these new techniques in the near future.

Management of non-acute gastrointestinal defects using the over-the-scope clips (OTSCs): a retrospective single-institution experience

INTRODUCTION

Advanced endoscopic techniques provide novel therapies for complications historically treated with surgical interventions. Over-the-scope clips (OTSCs) have recently been shown to be effective at endoscopic closure of gastrointestinal (GI) defects. We hypothesize that by following classic surgical principles of fistula management, a high rate of long-term success can be achieved with endoscopic closure of non-acute GI tract defects.

METHODS

A retrospective review of a single-institution prospectively maintained database (2012-2015) of all patients referred for the management of GI leaks or fistulae who underwent attempted closure with the OTSC system (Ovesco, Germany) was performed. Acute perforations were excluded. The primary endpoint was long-term success defined by the absence of radiographic or clinical evidence of leak or fistula during follow-up. Patients were stratified by success or failure of OTSC closure and compared with Fisher's exact and Mann-Whitney U tests.

RESULTS

We identified 22 patients with 28 defects (22 fistulae and 6 leaks). Most patients were female (59 %) with a mean age of 54 years (±14), median BMI of 29, and prior bariatric procedure (55 %). Comorbidities included smoking history (68 %) and diabetes (23 %). The majority of defects were solitary (64 %), involved the upper GI tract (82 %), and had been present for >30 days (50 %). Multiple therapeutic interventions were necessary in 46 % of defects. There were no adverse outcomes related to OTSC placement or misfiring. Endoscopic adjuncts were used in 61 % of cases. Overall success rate was 82 % (100 % for leaks and 76 % for fistulae) at a median follow-up of 4.7 months (IQR 2.1-8.4 months). Predictors of success and failure could not be distinguished due to limited sample size.

CONCLUSIONS

Over-the-scope clips can be safely and effectively used in patients presenting with GI leaks and fistulae. Further research is required to characterize the determinants of long-term success and risk factors for failure.

Comprehensive management of full-thickness luminal defects: The next frontier of gastrointestinal endoscopy

Full thickness gastrointestinal defects such as perforations, leaks, and fistulae are a relatively common result of many of the endoscopic and surgical procedures performed in modern health care. As the number of these procedures increases, so too will the number of resultant defects. Historically, these were all treated by open surgical means with the associated morbidity and mortality. With the recent advent of advanced endoscopic techniques, these defects can be treated definitively while avoiding an open surgical procedure. Here we explore the various techniques and tools that are currently available for the treatment of gastrointestinal defects including through the scope clips, endoscopic suturing devices, over the scope clips, sealants, endoluminal stents, endoscopic suction devices, and fistula plugs. As fistulae represent the most recalcitrant of defects, we focus this editorial on a multimodal approach of treatment. This includes optimization of nutrition, treatment of infection, ablation of tracts, removal of foreign bodies, and treatment of distal obstructions. We believe that by addressing all of these factors at the time of attempted closure, the patient is optimized and has the best chance at long-term closure. However, even with all of these factors addressed, failure does occur and in those cases, endoscopic therapies may still play a role in that they allow the patient to avoid a definitive surgical therapy for a time while nutrition is optimized, and infections are addressed.