Brian S. Lim, MD, MCR, from the Department of Gastroenterology, Kaiser Permanente Riverside Medical Center/University of California, Riverside, School of Medicine, in Riverside, California, USA writes about this VideoGIE case “Weaving through the twists and turns of the fish bone case: demonstration of 2 different indications for endoscopic suturing in a single case of esophageal leak.”

A 42-year-old male presented with dyspnea and chest/back pain after eating fish soup. CT showed a 1.5 cm rod-like object in the esophagus and pneumomediastinum. A fish bone was retrieved during surgery and perforation repaired. The patient had shortness of breath on post-operative day 4. Esophagram showed a leak.

Non-adherence of surgical wound was seen on EGD and closed with endoscopic suturing device. Esophagram 4 days later showed recurrent leakage; fully-covered metal stent was placed. However, patient’s symptoms returned after 2days and chest x-ray revealed distal stent migration. A third EGD was performed for stent re-position and fixation with endoscopic suturing. A follow-up esophagram in 2 weeks was negative. EGD few days thereafter showed distal migration of the stent. Interestingly, patient stated that reflux symptoms he had after stent placement completely resolved several days prior to the latest procedure, which likely coincided with the timing of stent dislodgement.

Current indications for endoscopic suturing include closure of tissue defects, bariatrics, and fixation of self-expandable metal stents (SEMSs). Closure of defects has been demonstrated with post-gastrostomy fistulas, defects after EMR/ESD, NOTES, and adverse events such as perforations/leaks. Multiple sessions may be required to achieve success. High rate of SEMS migration (benign indications) has been reported and recent studies proved endoscopic suturing of SEMS safe and effective.

We wanted to showcase this video because this particular clinical scenario demonstrated two different indications for the usage of endoscopic suturing system, direct suturing of tissue defects and fixation of stents.  The ex-vivo demonstration was added so that the viewers can more easily witness the different steps involved in application of the endo-stitch device.

Multiple sessions may be required to achieve success in closing post-surgical leaks/fistulas endoscopically and thus persistence is crucial.  Endoscopic suturing devices play an important role in current management of gastrointestinal tissue defects from various causes.

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