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ACG Case Rep J
ACG Case Rep J
ACGCRJ
AC9
ACG Case Reports Journal
2326-3253
Wolters Kluwer Maryland, MD

ACGCR-24-0292
10.14309/crj.0000000000001493
00015
3
Case Report
Endoscopy
Endoscopic Through-the-Scope X-Tack Helix Suturing System for Complete Closure of a Large Full-Thickness After Surgical Gastric Perforation
https://orcid.org/0000-0002-7611-1191
Almasaid Sharifeh MD 1
Suhail Fathima Keshia MD 2suhailf@upstate.edu

Khan Hafiz M. MD 2khanha@upstate.edu

1 Department of Internal Medicine, State University of New York Upstate Medical University Hospital, Syracuse, NY
2 Division of Gastroenterology, Department of Internal Medicine, State University of New York Upstate Medical University Hospital, Syracuse, NY
Correspondence: Sharifeh Almasaid (Almasais@upstate.edu).
9 2024
11 9 2024
11 9 e0149327 3 2024
31 7 2024
© 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology.
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

ABSTRACT

Gastric perforation is considered a surgical emergency managed operatively; however, endoscopic repair techniques have gained popularity as they are cost-effective, improve mortality, and decrease hospital stay and recurrence. With increased prevalence of gastric defects postoperatively and after invasive endoscopic procedures, various endoscopic techniques were developed over the years, but special consideration should be given to the defect type, size, and location. Our case highlights the use of X-Tack through-the-scope suturing for closing a large, full-thickness gastric perforation in a difficult location where OverStitch is not feasible.

KEYWORDS:

perforation
endoscopy
OverStitch
through-the-scope suture
OPEN-ACCESSTRUE
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pmcINTRODUCTION

Gastric perforation is a full-thickness stomach wall defect causing gastric content spillage into the peritoneal cavity. It can stem from intrinsic pathology such as peptic ulcer disease, iatrogenic as an after surgical complication, or spontaneously as in cases of inflammation or connective tissue diseases.1 Gastrointestinal (GI) wall continuity loss is a surgical emergency, requiring prompt surgical closure. However, advancement in endoscopic techniques led to shift toward minimally invasive methods for managing after surgical complications such as leaks, bleeding, perforation, strictures, stenosis, and fistulae. These techniques mitigate the need for reoperation, reducing cost, hospital stay, and mortality.2–5

With the increasing role of endoscopy in diagnostic and therapeutic interventions, it is crucial for endoscopists to skillfully manage procedure-related complications. This is particularly vital with the rise of third-space endoscopy techniques, such as endoscopic submucosal dissection, and per oral endoscopic myotomy, as perforations have been reported as a procedural complication, influenced by the endoscopist experience, also reported in more conventional procedures such as endoscopic retrograde cholangiopancreatography and endoscopic mucosal resection.6,7

Various endoscopic closure techniques exist, each tailored to specific indications based on the defect type, size, and location. These include but not limited to self-expanding metal or plastic stents, tissue sealants such as fibrin glue, endoclips, and endoscopic suturing devices.7,8

X-Tack (Apollo Endosurgery, Austin, TX) is an endoscopic device used for deep submucosal defect closure through a standard endoscope. The barbs allow for enhanced fixation in deep submucosal tissue using 4 points of fixation with HeliX Tacks. The suture cinch facilitates final suture tension and closure.9,10 This device has significant gains in immediate technical success and faster healing for lesions >30 mm compared with the through-the-scope suturing (TTSS) clip closure; it is easy to learn when compared with OverStitch device and does not need withdrawal during the procedure, which makes it more user friendly.11,12

In this article, we describe a case of X-Tack TTSS for endoscopic closure of a large after surgical full-thickness perforation in the posterior gastric wall.

CASE REPORT

A 41-year-old White man with a history of hypertension, presented with chest pain and abdominal bloating, experiencing hemorrhagic shock necessitating multiple blood transfusions. Imaging revealed a substantial abdominal collection with contrast extravasation concerning for a large intraperitoneal/retroperitoneal mass. Following an aortogram, he underwent left gonadal artery embolization and placement of a percutaneous intra-abdominal drain.

After the procedure, he required multiple transfusions and developed abdominal compartment syndrome requiring decompressive laparotomy; revealing a large, encapsulated mass occupying most of the abdomen; and necessitating extensive surgical interventions, including mass resection, left hemicolectomy, diaphragmatic resection, splenectomy, and partial gastrectomy near the posterior greater curvature. Final pathology confirmed sarcoma. Despite interventions, his condition worsened, prompting a return to the operating room for abdominal washout, gastrojejunostomy tube placement, perinephric drain insertion, and abdominal closure.

A month later in his hospital stay, tube feeds were observed to drain from the perinephric tubes. The patient did not have acute change in symptoms; he was intubated, sedated, and had an unremarkable abdominal examination. Evaluation by the interventional radiology team indicated that the perinephric drain was in good position, raising concerns about a potential gastric leak or luminal perforation near the staple line.

An upper GI series was performed, which revealed a leak near the gastric cardia, followed by upper endoscopy that revealed 4–5 cm long nonbleeding perforation on the posterior stomach wall, just below the gastroesophageal (GE) junction (Figures 1 and 2). Methylene blue injected through the perinephric drain identified the defect, which refluxed into the stomach, leading to the decision for endoscopic repair of the gastric perforation. OverStitch (Apollo Endosurgery) endoscopic suturing system was initially considered as its curved needle allows placing full-thickness sutures with the control of the needle depth. Given the proximity of the defect to the GE junction and limited space to maneuver the OverStitch device, it was decided to use X-Tack suturing device (Apollo Endosurgery). The defect was closed with three 3.0 polypropylene sutures in an interrupted fashion with cinches on both ends, and excellent tissue approximation was achieved (Figure 3). After the procedure, the perinephric drain no longer yielded gastric contents, and computed tomography of the abdomen with oral contrast ruled out any further leak, confirming complete closure of the gastric perforation (Figure 4). He tolerated tube feeding after. Subsequently, the drain was removed, and the patient was discharged home.

Figure 1. An upper gastrointestinal series showing a leak near the gastric cardia.

Figure 2. (A, B) Upper endoscopy showing the 4–5 cm long nonbleeding perforation on the posterior stomach wall, just below the gastroesophageal (GE) junction.

Figure 3. (A, B) Upper endoscopy showing a closed defect with polypropylene sutures in an interrupted fashion with cinches on both ends, and excellent tissue approximation was achieved.

Figure 4. (A, B) Computed tomography of the abdomen with oral contrast in coronal (A) and axial (B) cuts with no leak identifies that confirmed complete closure of the gastric perforation.

DISCUSSION

GI perforations can result from direct full-thickness injury or progression from partial-thickness injury. GI leaks involve a disruption in the surgical anastomosis continuity, occurring shortly after surgery or influenced by factors such as infection, inflammation, or conditions raising intestinal pressure, such as bowel obstruction.13

Leaks, perforations, and fistulae are distinct transmural GI defects arising from different mechanisms and requiring specific approaches. Leaks typically occur during surgery, perforations are often identified after bariatric and endoscopic interventions, and fistulae can develop from various factors, such as the expansion of surgical leaks or specific disease states.14 These defects result from inadequate tissue healing due to hypoperfusion and ischemia along suture lines, leading to increased morbidity and mortality.15,16 Leaks are the most common complication after bariatric procedure, occurring in 7% of gastric sleeve surgeries and 2%–19% of colorectal surgeries, increasing morbidity by 61%. While mortality from fistula formation ranges from 0.8% to 27%, endoscopy has played a role in over 90% for esophageal perforations and fistulas, and over 70% of leaks repair.2,17

Recent advances in endoscopic techniques in repairing GI wall defects have been attributed to improved morbidity and mortality compared with traditional surgical alternatives.18 Furthermore, the endoscopic approach provides diverse techniques such as direct closure using through-the-scope clips, over-the-scope clips, endoscopic suturing, luminal stents, and secondary intention closure with endoscopic internal drainage or the use of an endoscopic vacuum-assisted system.6,18 While each technique has specific advantages and disadvantages, the fundamental principles guiding the management of gastric defects hinge on crucial factors such as location, dimensions, and depth of the defect; draining any leaked materials; controlling luminal content flow and procedure cost; and assessing the necessary expertise for optimal decision making.13,18,19 By contrast to TTSS clips and over the scope clips, X-Tack offers advantages for larger, irregular-shaped submucosal defects. Closure of these defects can be accomplished without endoscope withdrawal or a bulky mounting system, such as OverStitch, which allows for additional maneuverability. The benefit of OverStitch however is the ability to provide full-thickness closure without limitations on defect size. A study evaluated X-Tack endoscopic suturing technique for different indications showed a success rate of 100% in repairing ulcers but only 66.7% for perforations and 54.4% for fistulas repair; OverStitch device was used as a salvage method in some cases with success, confirming that although this device nowadays is more recognized in full-thickness defects, it is still better suited for superficial defects.19,20 In our case, OverStitch was initially considered but due to limited space in the proximal end of large defect, where it was approaching the GE junction from the gastric cardia, was difficult to maneuver, and decision was made to use X-Tack sutures to repair the perforation.

As technology advances, there is a shift toward an innovative endoscopic tack and suture instrument, such as the X-Tack Endoscopic HeliX Tacking System. This device is designed to effectively seal substantial, broad, and irregularly shaped openings in the upper and lower GI tract. Compared with the OverStitch device, it is approximately half the cost. Consequently, there is a keen interest in establishing optimal protocols and cost-effective solutions for using these diverse closure devices.11,12

Our case highlights the effectiveness of X-Tack TTSS in closing a challenging full-thickness defect, especially in locations where OverStitch endoscopic suturing system may not be practical. Although various endoscopic alternatives are currently used, there is a lack of a standardized evidence-based protocol for addressing GI defects. Successfully managing leaks and fistulae in the GI system requires a personalized and collaborative strategy, considering factors such as clinical presentation, defect characteristics (size, location, and onset), local expertise, a multidisciplinary approach, and equipment accessibility.

DISCLOSURES

Author contributions: S. Almasaid: manuscript writing; FK Suhail: revision and editing; HM Khan: revision and editing, final approval for manuscript.

Financial disclosure: None to report.

Previous presentation: Case was presented as an abstract in the ACG Annual Scientific Meeting; October 20–25, 2023; Vancouver, BC, Canada, and received a Presidential Poster Award.

Informed consent was obtained for this case report.
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