Post written by Shailendra Singh, MD, and Ayowumi A. Adekolu, MD, from West Virginia University, Morgantown, West Virginia, USA.

We present a case series showing the use of a through-the-scope suturing (TTSS) system (X-Tack; Apollo Endosurgery, Austin, Tex, USA) for fixing 2 fully covered self-expandable metal stents (FCSEMSs) for creating longer stents as well as mitigating the risk of migration to manage larger GI defects.

After deployment of the metal stents in a tandem fashion with overlapping segments, stent-in-stent endoscopic suturing using the TTSS device is performed. The overlapping parts of the stents are fixed to each other with tacks and cinched. In addition, tacks can be placed at the proximal end of the stent to fix it to the GI wall to prevent migration.

FCSEMSs are commonly used for managing GI adverse events such as perforations, leaks, fistulas, and strictures. Stent length and migration can be limiting when dealing with larger defects. Over-the-scope clips and over-the-scope suturing can be used to mitigate migration risk.

However, their role is limited for stent-to-stent suturing because of their larger size and diameter, restricting their use in difficult and narrow spaces in the GI tract. We use TTSS for stent-to-stent suturing for creating longer stents to manage larger GI defects.

TTSS is compatible with most endoscopes and can be navigated to challenging narrow and angulated locations, giving it an advantage versus over-the-scope suturing and over-the-scope clips. Our case series demonstrates that stent-in-stent fixation of multiple FCSEMSs to create longer stents using the TTSS system is an effective technique when managing larger GI defects.

Overlapping fully covered self-expandable metal stents that are fixated into the esophageal wall using 4 tacks each at 2 separate sites within the overlapping area with 2 cinches placed.

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