UMass Chan Medical School

Prashanth Rau

Perforation during endoscopy is one of the most dreaded complications for any gastroenterologist. The American Society of Gastrointestinal Endoscopy (ASGE) multicenter registries report a perforation rate of 1 in 2500 or in about 11,000 cases. The presence of Zenker’s diverticulum, esophageal strictures, malignancies of the upper GI tract, and duodenal diverticula appear to be the greatest risk factors of perforation during an upper endoscopy. Alternatively, per the American Gastroenterology Association (AGA), Endoscopic Mucosal Resection (EMR) or Endoscopic Submucosal Dissection (ESD) for polyp resection appear to be the highest risk factors during colonoscopy. Historically, perforation closure has been in the domain of surgery due to the need for peritoneal washout, and due to the lack of endoscopic tools to close a perforation. However, a number of devices have now entered the market that give endoscopists the ability to close perforations and protect a patient from further surgery. As endoscopy has evolved to become more therapeutic, so has our ability to remedy our mistakes.

The endoscopic approach to perforation closure has many variables. Perforation location (i.e., esophagus, stomach, colon, etc.), size of perforation, and concern for peritoneal spillage all come into play. Recent expert opinion from the AGA recommends that upper GI tract perforations <2cm can be closed with though the scope clips, while lesions >2cm require endoscopic suturing. During colonoscopy a large number of perforations occur in the sigmoid colon due to looping. Additionally, perforations in the right side of the colon can present a challenge given that over the scope suturing devices or clips are difficult to maneuver to that side of the colon. Given that perforations may be in difficult endoscopic positions the advent of through the scope suturing devices gives the endoscopist the chance to close a perforation no matter its location.

Our center has the most experience with a through the scope helical tack system known as X-tack (Apollo Endosurgery Austin TX, USA). X-Tack allows for suture-based, deep submucosal and intramuscular enhanced fixation through a standard gastroscope or colonoscope. This device uses up to four tacks that are connected to each other in series with polyurethane suture. The tacks are drilled into the mucosa adjacent to a perforation in a “Z” pattern and then tightened. A cinch is deployed to then hold the tack in place. The system has multiple advantages, the first being its ease of use. Tacks are already pre-packaged in series, and the tack holster attaches to any endoscope in the same fashion as the wire locking device with ERCP, keeping the device organized. Because it is a through the scope system the gastroscope or colonoscope does not need to be removed from the patient allowing an endoscopist to keep their target in view. Tacks are passed through the working channel of a standard scope similar to hemostatic clips. A therapeutic endoscope is not required for X tack, which means the endoscopist does not have to switch endoscopes during the procedure. This is an advantage compared to over-the-scope suturing devices require a dual channel endoscope. The tacks are then drilled into the mucosa using a simple hand driver in an opening and closing motion similar to opening or closing a snare polypectomy device. Once four tacks are in place the suture is tightened by hand and cinch is deployed using the hand driver. The familiarity of these motions makes X tack easy to use for techs working with the endoscopist. Because of its ease of use, and familiar motions to deploy tacks, nearly all of our endoscopists and techs have quickly become proficient in set up, usage, and problem solving with the X tack system.

“A number of devices have now entered the market that give endoscopists the ability to close perforations and protect a patient from further surgery”

Using X tack we have closed gastric perforations that did not initially seal with attempted Graham patch closure, as well as closure of perforations in the lateral posterior wall of the duodenum. The latter case being a perforation in a notoriously difficult area to deploy over the scope suturing. Through our experience we have also noted an emerging advantage of X tack. As noted before the AGA recommends perforation closure of <2cm with hemostatic clips as first line. However, we have had cases where a perforation does not close with hemostatic clips. X tack has provided salvage therapy because the tacks can be placed very accurately, and in a manner that the suture traverses around previously placed foreign bodies (i.e., failed hemostatic clips). These perforations were successfully closed with X tack even though hemostatic clips cluttered the field. This ability is essential in a device system that may be used as salvage therapy.

Finally, through the scope suturing devices allow us to close perforations via an incisionless platform (i.e., endoscopy). By closing a perforation immediately, we reduce patient hospitalization time, as well as precious resources such as the need for laparoscopic or open laparotomy. Tools such as this help the hospital by reducing inpatient stays, help the endoscopist by giving them more tools, and also give patients a better chance for a safe and speedy recovery.