The Usefulness of an Endoscopic OverStitch Suturing System for Managing Anastomotic Dehiscence – A Case Report

Abstract

Anastomotic dehiscence (AD) after colorectal surgery contributes to poor outcomes resulting in multiple postoperative complications. Conventional management would be a repeat laparotomy and tension suturing. But owing to the unhealthy vicinities near the suture lines, there is a significant risk of technical failure which further increases postoperative morbidity and mortality. A 60-year-old male, with a history of hypertension, ischemic heart disease, and previous percutaneous transluminal coronary angioplasty, underwent sigmoid colectomy with colorectal anastomosis for complicated sigmoid diverticulitis. He then developed anastomotic site leak for which an ileostomy was done. Prior to the ileostomy revision, he was referred for colonoscopic evaluation which showed the persistence of a partial AD. We decided to close the defect endoscopically with the Apollo OverStitch device. Initial tissue preparation was done by creating a surgical surface using argon plasma coagulation at the perimeter of the leak site. A double channel therapeutic endoscope with the OverStitch assembly was passed to take full-thickness running sutures across the rent to facilitate full closure. The area examined showed good suture approximation and complete closure. The procedure was successful with no immediate or delayed postprocedural complications. Repeat endoscopic evaluation at about two weeks showed well-approximated edges with intact suture lines, and there was complete resolution of the leak. The patient subsequently underwent revision surgery after a month. The patient is under close follow-up and doing well. The Apollo OverStitch device has certainly opened new avenues in flexible endoscopic surgery which need further exploratory studies to add to existing promising results.

Oesophageal perforation by migrated Ryles tube

“…5 Small defects may be closed by an overstitch endoscopic suturing system. 6 Oesophagectomy with gastric pull-up is reserved for very large defects or where endoscopic therapy fails.…”

Assessment and Techniques for Endoscopic Closure

“…23,38 The major disadvantages are that it has a very steep learning curve, typically requires a double channel scope, requires working room, and can take up to an hour to close defects. 39 The learning curve can be improved with training courses and experience but even with trained endoscopists in animal training models the median time to place four to six sutures was 57.5 minutes. 40 If endoscopic suturing is performed incorrectly, there is the possibility of obstructing the lumen or worsening the size of the defect.…”