Endoscopic Suturing Device Allows for More Reliable Repair of Duodenal Perforations and Potentially Safer NOTES

Endoscopic suturing device technology has improved in recent years. In addition, it has brought improved success in the immediate repair of selected GI perforations and the potential to allow natural orifice transluminal endoscopic surgery (NOTES) to be performed in a safer and more effective way.1 Marking the first documented use of the Overstitch™ endoscopic suturing device (Apollo Endosurgery, Austin, Texas) for the repair of a duodenal perforation in conjunction with a NOTES abdominal washout, the Penn State Health Milton S. Hershey Medical Center team of Abraham Mathew, M.D., Matthew T. Moyer, M.D., M.S., and fellow, Ryan Gaffney, D.O., presented their success with this technique at the third annual American College of Gastroenterology international endoscopy video competition in October 2015, Honolulu, Hawaii.2 The video presented two cases in which surgery-sparing endoscopic repair of a duodenal perforation was successfully employed. As Dr. Gaffney explains, “In both cases, the risks of morbidity or mortality with open or laparoscopic surgery were considered very high and an endoscopic approach was regarded as a potentially safer, life-saving option.”

In the first case, endoscopic suturing was used to successfully repair an iatrogenic duodenal perforation in a 71-year-old female who underwent a complicated laparoscopic cholecystectomy at an outside hospital. In the second case, a NOTES approach was used to successfully cleanse the contaminated abdominal cavity following a subacute duodenal perforation. The patient was a 49-year-old male with multiple endocrine neoplasia (MEN) type 1, complicated by previous duodenal perforations requiring open patch repairs and multiple surgeries, making a proposed endoscopic approach to duodenal repair more attractive to additional surgery. The Overstitch device was used to endoscopically repair the duodenal defect. Complete defect closure was confirmed both intra-procedurally and post-operatively for both patients, each having uncomplicated recoveries. The female patient will still require a subsequent hepaticojejunostomy performed as an outpatient.

Dr. Moyer notes, “We’ve been increasingly using the Overstitch suturing technology with success in surgery-sparing procedures, which will require luminal defect closure in highly morbid patients. The two duodenal repair cases highlighted in the video illustrate its use in patients who would otherwise face very high risks if they underwent more conventional surgical repair.”

CT Image

A. CT image confirming acute duodenal perforation with free air and contrast extravasation outside the duodenum (arrow). B. Endoscopic views of an acute duodenal perforation in the second portion of D2 (Top panel) with widespread contamination of the abdomen and adjacent structures including the surface of the liver (Bottom panel). C. Successful endoscopic suture repair of the duodenal perforation seen on upper endoscopy performed four days after initial closure.

Effective, reliable means of defect closure has been identified as one of the 11 major barriers to the clinical application of NOTES procedures. The current advancements in endoscopic suturing may be helping to eliminate this critical barrier. The American Society of Gastrointestinal Endoscopy and the Society of American Gastrointestinal and Endoscopic Surgeons (ASGE/SAGES) Working Group has outlined several barriers that limit NOTES clinical application3; these also include development of an adequate multitasking surgical platform, establishing/maintaining the pneumoperitoneum, visualization/orientation, and methods for addressing intraoperative complications, such as hemorrhage, tears, or perforation.

Matthew T. Moyer, M.D.Matthew T. Moyer, M.D., M.S.
Associate Professor of Medicine
PHONE: 717-531-6261
E-MAIL: mmoyer@hmc.psu.edu
FELLOWSHIP: Gastroenterology, Penn State Health Milton S. Hershey Medical Center, Hershey, Pa.
RESIDENCY: Internal medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, Pa.
MEDICAL SCHOOL: Penn State College of Medicine, Hershey, Pa.

Connect with Matthew Moyer, M.D. on Doximity

Ryan Gaffney, D.O.Ryan Gaffney, D.O.
Gastroenterology Fellow
PHONE: 717-531-6261
E-MAIL: rgaffney@hmc.psu.edu
FELLOWSHIP: Gastroenterology, Penn State Health Milton S. Hershey Medical Center, Hershey, Pa.
RESIDENCY: Penn State Health Milton S. Hershey Medical Center, Hershey, Pa.
MEDICAL SCHOOL: Des Moines University Osteopathic Medical Center, Des Moines, IA

Connect with Ryan Gaffney, D.O. on Doximity


  1. Baron T, Wong Kee Song L, Zielinski M, Emura F, Fotoohi M, Kozarek R. A Comprehensive Approach to the Management of Acute Endoscopic Perforations (with videos). Gastrointest Endosc 2012; 76(4):838-59.
  2. Gaffney R, Moyer M, Gusani N, Wong J, Saunders B, Mathew A. A NOTES Approach to Acute Duodenal Perforation: A Minimally Invasive Approach Made Possible by an Effective Endoscopic Suturing System. Live from Honolulu! The 3rd Annual Endoscopy Video Forum. American College of Gastroenterology 2015 Annual Scientific Meeting. Honolulu, Hawaii. Monday October 19, 2015.
  3. Rattner D, Kalloo A; ASGE/SAGES Working Group. 2006. ASGE/SAGES Working Group on Natural Orifice Translumenal Endoscopic Surgery. 2005; Surg Endosc. 2006;20(2):329-33.

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