Introduction

Treatment of complex fistula and residual anastomotic insufficiencies remain a challenge even in an interdisciplinary setting. Endoscopic standard techniques for closure like clips, OTSC or SEMS are limited to special indications. Endoscopic suturing may offer an approach to close complex fistula orifices.

Aims & Methods

Endoscopic suturing was used for interventional closure of complex insufficiencies in the lower GI-tract. 5 consecutive patients were treated using standard Endosuturing (SutuArt, Olympus) or modified suture strategy using an additional working channel (ACEES). In three patients residual insufficiencies in the rectum were visible after complex vacuum therapy. In one patient a recto-vaginal fistula was clinical apparent. In one patient an iatrogenic perforation was occurred within dilation therapy for anastomotic stenosis. Due to size or location of the defects a standard closure technique was either not applicable or failed in a prior attempt.

Results

Technical success, defined as macroscopic defect closure, was achievable in 5 of 5 patients. Mean time for intervention was 57(±14)min. For 3 patients bimanual work using additional working channel enhanced endoscopic suturing (ACEES) was performed. In endoscopic surveillance permanent closure was achieved in 4 of 5 patients.

Conclusion

Endoscopic suturing is a newly available technique. Beyond its basic indication for defect closure after ESD this procedure, also in combination with bimanual suturing (ACEES), may offer an excellent opportunity for treatment of complex fistula.

Disclosure

nothing to disclose

Introduction

Anastomotic leakage is a serious complication following colorectal surgery and is associated with early and long-term morbidity and mortality. Various endoscopic and surgical approaches have been established for management. A new therapeutic option involves the placement of a fully covered VACStent for the lower GI tract (36x80 mm, MICRO-Tech, Düsseldorf, Germany) which offers advantages such as completely covering the defect, continuous drainage, and facilitating stool passage simultaneously. Here we report our initial experiences with the VACStent in the lower GI tract for treatment of anastomotic leakage.

Aims & Methods

The fully covered VACStent (36x80 mm) was placed endoscopically under direct visualization. A continuous negative pressure between -75 and -125 mmHg was applied. The VACStent was flushed daily with 20 ml of saline to prevent adhesions of the open-pored sponge of the stent. Six hours before the stent extraction/exchange, the negative pressure was discontinued. The integrity of the leak closure was confirmed visually and via fluoroscopy.

Results

Between February and December 2024, we treated six patients with anastomotic leakage (rectal leakage n=4, sigmoid leakage n=2) using the VACStent. The leak was detected on the 6^th ± 3 postoperative day. The leak was successfully sealed with the VACStent and one to fife exchanges were performed. However, anastomotic leakages larger than 10 mm (n=2) required pretreatment with an EndoSponge (B.Braun, Melsungen, Germany) for a duration of 5 to 10 days. The leak closure with the VACStent occurred after 20 ± 6 days, with inflammatory parameters decreasing by around 85 ± 12%. Four patients received a protective stoma. The distance of the leak from the anal canal averaged 8 ± 7 cm. Patients with leaks involving the anal canal required pain relief. One patient experienced point-shaped erosion bleeding in the anal canal, which was effectively treated with APC. In two patients, the VACStent therapy could be completed in an outpatient setting.

Conclusion

The lower GI VACStent represents a novel promising and effective endoscopic treatment option for colonic anastomotic defects.

Introduction

The management of post-interventional and iatrogenic defects in the gastrointestinal tract presents significant challenges in endoscopic practice, often carrying substantial risks for patients. Various closure techniques have been developed, yet consistently effective outcomes remain elusive in diverse scenarios. Endoscopic free-hand suturing (EFHS) using a needle holder is a new technique that has demonstrated potential for effectively addressing these defects. In this study, we present one of the largest cohorts to date, analyzing the safety and feasibility of endoscopic free-hand suturing across multiple scenarios and locations.

Aims & Methods

This study aimed to investigate the feasibility and safety of EFHS and the attainability of sustained closure following various procedures: endoscopic submucosal dissection (ESD), perforation, per-oral endoscopic myotomy (POEM), per-oral endoscopic myotomy for Zenker's diverticulum (Z-POEM), submucosal tunneling endoscopic resection (STER), and endoscopic submucosal excavation (ESE).
ESD, or the respective above-mentioned interventions, were followed by EFHS, utilizing a gastroscope or colonoscope and a barbed absorbable wire (V-loc 180, Covidien, Dublin, Ireland). Needle steering involved a distal cap attachment and a needle holder (SutuArt; Olympus, Hamburg, Germany). Suturing was performed in a zigzag pattern at 5-10 mm intervals. For safety, the needle was concealed, and post-suturing, the remaining suture and needle were cut with a loop cutter (Olympus, Hamburg, Germany) for removal.

Results

In this retrospective single-center study, 30 post-interventional defects in 26 patients (female n = 10, male n = 16) and performed EFHS were retrospectively followed. Technical success, clinical success after the procedure, and severe EFHS-related adverse events were evaluated. EFHS was applied for defect closure after the following interventions and/or complications: colonic endoscopic submucosal dissection (n =10; ceacum n =4, ascending n = 1, transverse n = 2, sigmoid n = 3), rectal endoscopic submucosal dissection (n = 9), gastric subepithelial lesion removal (n = 2; STER n = 1, ESE n = 1) duodenal perforation (n = 1), colonic perforation (n = 1), peroral endoscopic myotomy (POEM) (n = 1), peroral endoscopic myotomy for the treatment of Zenker's diverticulum (Z-POEM) (n = 2). The median of the resected area was 1450 mm² (range 500 – 3600 mm²).
In none of the 26 patients were severe procedure-related events observed, specifically, there were no instances of bleeding or perforation.
Endoscopic follow-up was conducted in 15 of 30 EFHS closures, demonstrating adequate closure in 13 cases, in 2 cases in the rectum, the mucosa was partially dehiscent, although showing re-epithelialization. The median time between the intervention and endoscopic follow-up was 15 days (range 1 - 69 days). The median duration of hospital stay after endoscopic intervention was 2 days (range 1 – 5 days).

Conclusion

Endoscopic free-hand suturing is safe and feasible within the gastrointestinal tract, including esophagus, stomach, duodenum, colon and rectum. Endoscopic free-hand suturing has the potential to enhance the safety of endoscopic interventions and reduce hospital stay duration.

Introduction

Anastomotic leakage is a serious complication following colorectal surgery and is associated with early and long-term morbidity and mortality. Various endoscopic and surgical approaches have been established for management. A new therapeutic option involves the placement of a fully covered VACStent for the lower GI tract (36x80 mm, MICRO-Tech, Düsseldorf, Germany), which offers advantages such as completely covering the defect, continous drainage, and facilitating stool passage simultaneously. Here we report our initial experiences with the VACStent in the lower GI tract for treatment of anastomotic leakage.

Aims & Methods

The fully covered VACStent (36x80 mm) was placed endoscopically under direct visualization. A continuous negative pressure between -75 and -125 mmHg was applied. The VACStent was flushed daily with 20 ml of saline to prevent adhesions of the open-pored sponge of the stent. Six hours before the stent extraction/exchange, the negative pressure was discontinued. The integrity of the leak closure was confirmed visually and via fluoroscopy.

Results

Between February and April 2024, we treated four patients with anastomotic leakage (rectal leakage n=2, sigmoid leakage n=2) using the VACStent. The leakage was detected on the 7^th ± 4 postoperative day. The leak was successfully sealed with the VACStent, and one to two exchanges were performed. The leak closure occurred after 17 ± 3 days. Inflammatory parameters such as CRP decreased by around 85 ± 13%. Three patients had a stoma before the VACStent was placed. The distance of the leak from the anal canal averaged 10 ± 9 cm. Patients with leaks involving the anal canal required additional pain reliever. One patient experienced point-shaped erosion bleeding in the anal canal, which was effectively treated with APC.

Conclusion

The lower GI VACStent represents a novel promising and effective endoscopic treatment option for colonic anastomotic defects.

Clinical Case Summary