Endoscopic suturing offers a minimally invasive, incisionless repair of gastrointestinal perforations and fistulas which often occur in critically ill patients in an emergent setting. “With the new generation endoscopic suturing device that is available, the possibilities using an endoscopic approach have dramatically broadened; we can be much more aggressive with endoscopic treatments that used to be limited by traditional suturing methods,” says Abraham Mathew, M.D., Penn State Hershey Gastroenterology and Hepatology.
Physicians at Penn State Hershey Medical Center have been using the Apollo OverStitch™ (Apollo Endosurgery, Inc., Austin, Texas) since it became available in the U.S. They have noted large gains in their ability to use an endoscopic approach for a wider range of indications, including closure of GI fistulas, perforations of the GI lumen and suturing of endoscopic stents in place to avoid migration. Patients whose stomach pouches open widely after gastric bypass surgery can have it reduced using this device. The future holds endoscopic alternatives for laparoscopic sleeve gastrectomies and gastric bypass surgeries. A video of a procedure in which Mathew and his colleagues used the suturing device was shown during the 2015 Digestive Disease Week (May 16-19, Washington, District of Columbia).
Mathew adds, “We’ve also found this device useful for revision surgery to address complications, such as failure of staple closure or injuries to the gut, secondary to surgical procedures.” Often these are gravely ill patients who require emergent surgery, with historically poor outcomes and a high risk of morbidity and mortality. Open secondary repair procedures add to risks, heightening the chances of complications, and necessitating large abdominal wounds, or major tissue resection. Mathew explains, “By using an endoscopic approach paired with endoscopic suturing, we completely avoid incisions and can often limit tissue resection. This decreases the risk seen with major open procedures.
Often, patients have a shorter and more comfortable hospital stay, with less pain. “One patient who experienced a perforation of the colon was in pain only for a few hours and was discharged home in 72 hours. It is very exciting that we can accomplish this without a skin incision,” says Mathew.
Mathew and his colleagues report having used the device in a total of 30 patients, six of these treated in the past two months. Mathew notes, “As we’ve gained experience with the device, we’ve found it’s easiest and optimal for closure of a fresh incision and at a favorable angle [between 12 o’clock and 7 o’clock]. There is a learning curve to master suturing in the intestinal lumen. However, even with significant challenges and difficult cases, the large gains in outcomes have been seen with its use in very gravely ill patients, where risks and tissue damage can be greatly reduced, compared to open surgery.”
Abraham Mathew, M.D.
Professor of Medicine
Fellowship: Gastroenterology, Penn State Milton S. Hershey Medical Center, Hershey, PA
Residency: Internal medicine, Abington Memorial Hospital, Abington, PA
Medical School: Mahathma Gandhi University, Kerala, India