Endoscopic through-the-scope suturing

There is growing interest in closure of larger mucosal defects, given the increasing use of endoscopic resection for early GI neoplasia and the advent of submucosal endoscopy, including peroral endoscopic myotomy. Existing closure methods include through-the-scope clips, over-the-scope clips, and over-the-scope suturing. Although over-the-scope clips and over-the-scope suturing allow closure of large defects, both require endoscope removal for device application and may have difficulty in treating lesions in the proximal colon or the small intestine. Hence, a significant gap exists for a through-the-scope device capable of closing larger defects. The novel X-Tack system (Apollo Endosurgery, Austin, Tex, USA) offers through-the-scope suturing (TTSS), which eliminates the need to withdraw the endoscope from the patient before applying therapy.

We demonstrate the possible indications for endoscopic mucosal adhesion with TTSS through a video case series. We present 5 cases to illustrate the use of TTSS in the closure of a duodenal EMR defect, a cecal EMR defect, mucostomy after esophageal and gastric peroral endoscopic myotomy, and, finally, for primary closure of a gastrogastric fistula.

All defects were successfully closed with 1 to 2 TTSS systems. There were no postprocedure adverse events, including bleeding or perforation, at a median of 30 (range 14-30) days of follow-up.

TTSS is a valuable addition to mucosal closure devices, which allows closure through a gastroscope or a colonoscope, without requiring endoscope removal for device application. Likely applications include larger or more distant defects and those located within tight spaces. Pending further clinical evaluation, important areas for research include assessment of the learning curve, comparative trials with other closure devices, and cost-effectiveness analysis.