Post written by Maham Hayat, MD, from the Center for Interventional Endoscopy, AdventHealth, Orlando, Florida, USA.

We present a case of a patient with an indwelling percutaneous gastrojejunostomy tube with a chronic perforation in the duodenum from the tip of the displaced tube. Attempt at endoscopic closure using an over-the-scope clip was unsuccessful because of the fibrotic and friable nature of the target defect.

The through-the-scope (TTS) suturing device permitted easy and effective closure in this otherwise challenging location in the duodenal bulb immediately beyond the pylorus.

Successful endoscopic closure of perforations can obviate the need for more invasive surgical interventions in frail patients. The X-Tack Endoscopic HeliX Tacking System (Apollo Endosurgery, Austin, Tex, USA) is a novel TTS suturing device approved by the U.S. Food and Drug Administration. This device has expanded our armamentarium for endoscopic tissue approximation.

Nonetheless, although TTS suturing has been shown to be a helpful device for mucosal defect apposition, its use for full-thickness closure remains to be determined. Our case highlights the potential application of this device for full-thickness closure in the duodenum.

The TTS suturing device is a recent addition to the ever-expanding endoscopic toolbox for closure devices. In this particular case, we demonstrate its use for full-thickness closure of a defect that would have been challenging to close with other devices, including over-the-scope clips and sutures. Increasing familiarity with all the devices and techniques at our disposal helps us understand the most suitable approach on a case-by-case basis.

Failed attempt to close the perforation with an over-the-scope clip because of the fibrotic and friable nature of the defect.

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