Repair of esophageal perforations using a novel endoscopic suturing system

The role of interventional endoscopy in the repair of esophageal perforations is growing. In the following case series, we demonstrate the utility and clinical success of endoscopic suturing with the Overstitch device (Apollo Endosurgery, Austin, Texas, USA) to treat emergent, life-threatening esophageal perforations.The first patient, a 54-year-old man with a significant history of alcohol abuse, presented to the emergency department with abdominal pain and shortness of breath, starting shortly after several retching episodes. CT of the abdomen and pelvis revealed an area of perforation at the distal esophagus, confirmed by a gastrografin esophagram, showing leakage of contrast medium into the left pleural space. The patient was given intravenous antibiotics and transferred to the intensive care unit.With the patient under general anesthesia, upper endoscopy revealed the site of perforation to be 25 mm long and located 2 cm proximal to the gastroesophageal junction (Fig. 1). The endoscope was exchanged for a dual-channel therapeutic endoscope, preloaded with the Overstitch device. An overtube was used to protect the oropharynx. Suturing was commenced, with placement of 4 interrupted sutures. The first suture was placed at the distal portion of the tear by working proximally. Endoscopic review revealed closure of the perforation (Fig. 1). The patient was transferred back to the intensive care unit. A follow-up gastrografin esophagram revealed complete closure of the fistula.The second patient, a 45-year-old man with a significant history of recurrent food bolus impactions, was transferred from an outside hospital where attempted endoscopic food bolus disimpaction had been unsuccessful.Upon transfer, repeated endoscopy with intravenous conscious sedation was performed, with use of an overtube for airway protection. A large food bolus impaction with surrounding erythema was observed at 30 cm. The food bolus was suctioned by use of a suction cap and was removed. Upon review, the food bolus was resolved, but a deep tear at 30 cm was seen (Fig. 2A). Physical examination revealed crepitance, stable vital signs, and oxygen saturation.Figure 2A, Endoscopic view of the esophageal perforation after food bolus disimpaction. B, Subsequent closure with endoscopic suturing.View Large Image Figure ViewerDownload Hi-res image Download (PPT)While the patient was under conscious sedation, during the same procedure, the endoscope was exchanged for a dual-channel therapeutic endoscope with the Overstitch device attached. Suturing was commenced, with placement of 4 sutures in a running fashion (Fig. 2B). Upon review, the site of perforation appeared closed. The patient was given broad-spectrum antibiotics and transferred to a monitored medical bed. Surgical consultation was obtained. The next day, a gastrografin esophagram revealed no evidence of esophageal leak. The patient felt well and required no further intervention. He was discharged from the hospital 2 days later and was instructed to use a soft diet.The third patient, an 83-year-old woman with multiple cardiac comorbidities, underwent an elective transesophageal echocardiogram to evaluate a possible cardiac shunt. Several hours after her procedure, the patient experienced neck pain and swelling. A gastrografin esophagram revealed esophageal perforation within the upper portion of the esophagus. Given the patient's age and comorbidities, attempts at conservative medical management with strict observance of nothing by mouth and total parenteral nutrition were initiated. However, on hospital day 9, a repeated esophagram revealed persistent extravasion of contrast medium through the upper to the mid portion of the esophagus. A gastroenterology consultation was requested for assistance.With the patient under general anesthesia, upper endoscopy was performed, revealing a 1.5-cm perforation, approximately 1 cm distal to the upper esophageal sphincter (Fig. 3A). The thoracic cavity was entered, and 300 mL of serosanguinous fluid was aspirated from the right side of the chest. The gastroscope was exchanged for a dual-channel therapeutic endoscope, preloaded with the Overstitch device. A total of 5 interrupted sutures were required to seal off the perforation (Fig. 3B). A gastrografin esophagram the following day revealed no evidence of contrast medium extravasion. The patient was later transferred to a medical bed and given a clear liquid diet.Figure 3A, Esophageal-mediastinal fistula. B, Closure of perforation with endoscopic suturing.View Large Image Figure ViewerDownload Hi-res image Download (PPT)The role of interventional endoscopy in early emergent perforation is growing, with the use of metallic clips, fully covered self-expandable metallic stents, and endoscopic suturing. Some of the drawbacks of fully covered self-expandable metallic stents include hyperplastic overgrowth, nonhealing leaks upon stent removal, and stent migration.1Eloubeidi M.A. Talreja J.P. Lopos T.L. et al.Success and complications associated with placement of fully covered removable self-expandable metal stents for benign esophageal diseases (with videos).Gastrointest Endosc. 2011; 73: 673-681Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar, 2Swinnen J. Eisendrath P. Rigaux J. et al.Self-expandable metal stents for the treatment of benign upper GI leaks and perforations.Gastrointest Endosc. 2011; 73: 890-899Abstract Full Text Full Text PDF PubMed Scopus (137) Google ScholarPublished medical reports regarding the Overstitch device for the use of esophageal and GI perforations include case reports and series. Kantsevoy and Bitner3Kantsevoy S.V. Bitner M. Esophageal stent fixation with endoscopic suturing device (with video).Gastrointest Endosc. 2012; 76: 1251-1255Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar evaluated the Overstich device in 7 patients for esophageal stent fixation. An average of 2 to 3 sutures were placed, and the overall procedural time averaged 26.4 minutes (±3.6 minutes). None of the esophageal stents migrated, and there were no adverse events.3Kantsevoy S.V. Bitner M. Esophageal stent fixation with endoscopic suturing device (with video).Gastrointest Endosc. 2012; 76: 1251-1255Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar In another study, Bonin et al4Bonin E.A. Wong Kee Song L.M. Gostout Z.S. et al.Closure of a persistent esophagopleural fistula assisted by a novel endoscopic suturing system.Endoscopy. 2012; 44: E8-E9PubMed Google Scholar described a case involving endoscopic suturing to close a chronic esophagopleural fistula in a 66-year-old woman. A 10-mm fistula, for which thoracostomy was unsuccessful, was successfully closed with 2 sessions of endoscopic suturing. A 3-stitch running suture was applied during the first session. Upon follow-up examination with contrast medium, the leak persisted. The defect was successfully closed with 3 interrupted sutures at a second session. In yet another study, Kurian et al described closure of an inadvertent full-thickness esophagotomy while performing mucosotomy during peroral endoscopic myotomy. With use of the Overstitch suturing device, the defect was successfully closed by using the Overstitch suturing device, and laparoscopy was prevented.5Kurian A.A. Bhayani N.H. Reavis K. et al.Endoscopic suture repair of full-thickness esophagotomy during per-oral esophageal myotomy for achalasia.Surg Endosc. 2013; 27: 3910Crossref PubMed Scopus (30) Google Scholar Finally, Chiu et al described successful endoscopic closure using the Overstitch device in 2 porcine models with full-thickness gastric submucosal tumor resections.6Chiu P.W. Phee S.J. Wang Z. et al.Feasibility of full-thickness gastric resection using master and slave transluminal endoscopic robot and closure by Overstitch: a preclinical study.Surg Endosc. 2014; 28: 319-324Crossref PubMed Scopus (41) Google Scholar Other suturing devices have also shown promise, including a full-thickness Plicator device used for closure of gastric wall defects and an endoluminal anchoring system.7von Renteln D. Riecken B. Walz B. et al.Endoscopic GIST resection using FlushKnife ESD and subsequent perforation closure by means of endoscopic full-thickness suturing.Endoscopy. 2008; 40: E224-E225Crossref PubMed Scopus (32) Google Scholar, 8Thompson C.C. Jacobsen G.R. Schroder G.L. et al.Stoma size critical to 12-month outcomes in endoscopic suturing for gastric bypass repair.Surg Obes Relat Dis. 2012; 8: 282-287Abstract Full Text Full Text PDF PubMed Scopus (40) Google ScholarThe Overstitch device proved to be relatively easy to use, with a short learning curve. A hands-on video, produced by our fellows and staff, assisted other physicians and staff members in using the device. After 1 or 2 cases, our medical team was well versed in preparing and applying sutures. The procedural times ranged from 25 to 45 minutes, with an average of 4 to 5 interrupted sutures placed per case. Some of the challenges of the device included “misfires,” wherein the needle would not load onto the needle driver. This was thought to be caused by early closure, and subsequent bending, of the needle driver. Our team adjusted by having an assistant hold the handle of the needle driver, which provided a more coordinated needle exchange. A focus of improvement in the design of the device would be to allow for a more coordinated needle exchange, thereby preventing bending of the needle driver.In conclusion, our case series demonstrates the utility and clinical success of endoscopic suturing with the Overstitch device to treat emergent, life-threatening esophageal perforations. The role of interventional endoscopy in the repair of esophageal perforations is growing. In the following case series, we demonstrate the utility and clinical success of endoscopic suturing with the Overstitch device (Apollo Endosurgery, Austin, Texas, USA) to treat emergent, life-threatening esophageal perforations. The first patient, a 54-year-old man with a significant history of alcohol abuse, presented to the emergency department with abdominal pain and shortness of breath, starting shortly after several retching episodes. CT of the abdomen and pelvis revealed an area of perforation at the distal esophagus, confirmed by a gastrografin esophagram, showing leakage of contrast medium into the left pleural space. The patient was given intravenous antibiotics and transferred to the intensive care unit. With the patient under general anesthesia, upper endoscopy revealed the site of perforation to be 25 mm long and located 2 cm proximal to the gastroesophageal junction (Fig. 1). The endoscope was exchanged for a dual-channel therapeutic endoscope, preloaded with the Overstitch device. An overtube was used to protect the oropharynx. Suturing was commenced, with placement of 4 interrupted sutures. The first suture was placed at the distal portion of the tear by working proximally. Endoscopic review revealed closure of the perforation (Fig. 1). The patient was transferred back to the intensive care unit. A follow-up gastrografin esophagram revealed complete closure of the fistula. The second patient, a 45-year-old man with a significant history of recurrent food bolus impactions, was transferred from an outside hospital where attempted endoscopic food bolus disimpaction had been unsuccessful. Upon transfer, repeated endoscopy with intravenous conscious sedation was performed, with use of an overtube for airway protection. A large food bolus impaction with surrounding erythema was observed at 30 cm. The food bolus was suctioned by use of a suction cap and was removed. Upon review, the food bolus was resolved, but a deep tear at 30 cm was seen (Fig. 2A). Physical examination revealed crepitance, stable vital signs, and oxygen saturation. While the patient was under conscious sedation, during the same procedure, the endoscope was exchanged for a dual-channel therapeutic endoscope with the Overstitch device attached. Suturing was commenced, with placement of 4 sutures in a running fashion (Fig. 2B). Upon review, the site of perforation appeared closed. The patient was given broad-spectrum antibiotics and transferred to a monitored medical bed. Surgical consultation was obtained. The next day, a gastrografin esophagram revealed no evidence of esophageal leak. The patient felt well and required no further intervention. He was discharged from the hospital 2 days later and was instructed to use a soft diet. The third patient, an 83-year-old woman with multiple cardiac comorbidities, underwent an elective transesophageal echocardiogram to evaluate a possible cardiac shunt. Several hours after her procedure, the patient experienced neck pain and swelling. A gastrografin esophagram revealed esophageal perforation within the upper portion of the esophagus. Given the patient's age and comorbidities, attempts at conservative medical management with strict observance of nothing by mouth and total parenteral nutrition were initiated. However, on hospital day 9, a repeated esophagram revealed persistent extravasion of contrast medium through the upper to the mid portion of the esophagus. A gastroenterology consultation was requested for assistance. With the patient under general anesthesia, upper endoscopy was performed, revealing a 1.5-cm perforation, approximately 1 cm distal to the upper esophageal sphincter (Fig. 3A). The thoracic cavity was entered, and 300 mL of serosanguinous fluid was aspirated from the right side of the chest. The gastroscope was exchanged for a dual-channel therapeutic endoscope, preloaded with the Overstitch device. A total of 5 interrupted sutures were required to seal off the perforation (Fig. 3B). A gastrografin esophagram the following day revealed no evidence of contrast medium extravasion. The patient was later transferred to a medical bed and given a clear liquid diet. The role of interventional endoscopy in early emergent perforation is growing, with the use of metallic clips, fully covered self-expandable metallic stents, and endoscopic suturing. Some of the drawbacks of fully covered self-expandable metallic stents include hyperplastic overgrowth, nonhealing leaks upon stent removal, and stent migration.1Eloubeidi M.A. Talreja J.P. Lopos T.L. et al.Success and complications associated with placement of fully covered removable self-expandable metal stents for benign esophageal diseases (with videos).Gastrointest Endosc. 2011; 73: 673-681Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar, 2Swinnen J. Eisendrath P. Rigaux J. et al.Self-expandable metal stents for the treatment of benign upper GI leaks and perforations.Gastrointest Endosc. 2011; 73: 890-899Abstract Full Text Full Text PDF PubMed Scopus (137) Google Scholar Published medical reports regarding the Overstitch device for the use of esophageal and GI perforations include case reports and series. Kantsevoy and Bitner3Kantsevoy S.V. Bitner M. Esophageal stent fixation with endoscopic suturing device (with video).Gastrointest Endosc. 2012; 76: 1251-1255Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar evaluated the Overstich device in 7 patients for esophageal stent fixation. An average of 2 to 3 sutures were placed, and the overall procedural time averaged 26.4 minutes (±3.6 minutes). None of the esophageal stents migrated, and there were no adverse events.3Kantsevoy S.V. Bitner M. Esophageal stent fixation with endoscopic suturing device (with video).Gastrointest Endosc. 2012; 76: 1251-1255Abstract Full Text Full Text PDF PubMed Scopus (57) Google Scholar In another study, Bonin et al4Bonin E.A. Wong Kee Song L.M. Gostout Z.S. et al.Closure of a persistent esophagopleural fistula assisted by a novel endoscopic suturing system.Endoscopy. 2012; 44: E8-E9PubMed Google Scholar described a case involving endoscopic suturing to close a chronic esophagopleural fistula in a 66-year-old woman. A 10-mm fistula, for which thoracostomy was unsuccessful, was successfully closed with 2 sessions of endoscopic suturing. A 3-stitch running suture was applied during the first session. Upon follow-up examination with contrast medium, the leak persisted. The defect was successfully closed with 3 interrupted sutures at a second session. In yet another study, Kurian et al described closure of an inadvertent full-thickness esophagotomy while performing mucosotomy during peroral endoscopic myotomy. With use of the Overstitch suturing device, the defect was successfully closed by using the Overstitch suturing device, and laparoscopy was prevented.5Kurian A.A. Bhayani N.H. Reavis K. et al.Endoscopic suture repair of full-thickness esophagotomy during per-oral esophageal myotomy for achalasia.Surg Endosc. 2013; 27: 3910Crossref PubMed Scopus (30) Google Scholar Finally, Chiu et al described successful endoscopic closure using the Overstitch device in 2 porcine models with full-thickness gastric submucosal tumor resections.6Chiu P.W. Phee S.J. Wang Z. et al.Feasibility of full-thickness gastric resection using master and slave transluminal endoscopic robot and closure by Overstitch: a preclinical study.Surg Endosc. 2014; 28: 319-324Crossref PubMed Scopus (41) Google Scholar Other suturing devices have also shown promise, including a full-thickness Plicator device used for closure of gastric wall defects and an endoluminal anchoring system.7von Renteln D. Riecken B. Walz B. et al.Endoscopic GIST resection using FlushKnife ESD and subsequent perforation closure by means of endoscopic full-thickness suturing.Endoscopy. 2008; 40: E224-E225Crossref PubMed Scopus (32) Google Scholar, 8Thompson C.C. Jacobsen G.R. Schroder G.L. et al.Stoma size critical to 12-month outcomes in endoscopic suturing for gastric bypass repair.Surg Obes Relat Dis. 2012; 8: 282-287Abstract Full Text Full Text PDF PubMed Scopus (40) Google Scholar The Overstitch device proved to be relatively easy to use, with a short learning curve. A hands-on video, produced by our fellows and staff, assisted other physicians and staff members in using the device. After 1 or 2 cases, our medical team was well versed in preparing and applying sutures. The procedural times ranged from 25 to 45 minutes, with an average of 4 to 5 interrupted sutures placed per case. Some of the challenges of the device included “misfires,” wherein the needle would not load onto the needle driver. This was thought to be caused by early closure, and subsequent bending, of the needle driver. Our team adjusted by having an assistant hold the handle of the needle driver, which provided a more coordinated needle exchange. A focus of improvement in the design of the device would be to allow for a more coordinated needle exchange, thereby preventing bending of the needle driver. In conclusion, our case series demonstrates the utility and clinical success of endoscopic suturing with the Overstitch device to treat emergent, life-threatening esophageal perforations. 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