CLOSED LOOP SMALL BOWEL OBSTRUCTION AFTER FULL THICKNESS DEFECT CLOSURE WITH THE ENDOSCOPIC HELIX TACKING SYSTEM

Background: Endoscopic defect closure have been applied to reduce the adverse events rate after colorectal endoscopic submucosa dissection (ESD). As for the suturing device, the closure has usually been performed using through-the-scope clips (TTSC). However, suturing of large defects is challenging because clips are usually small and insufficient for closing mucosal defects. In addition, closure of a large wound by simple clipping usually results in suturing only the mucosal layer, which could be unreliable. Suturing all layers of the colorectal wall, like surgical suturing, is important for achieving robust closure. Although closure with over-the-scope clips or over-the-scope sutures allows robust closure, even for large defects, these methods require expensive dedicated devices. In addition, delivery to the proximal colon is sometimes difficult and time-consuming. Therefore, a suturing method using only TTSC, which can perform robust closure even for large mucosal defects, is necessary. Endoscopic double-layered suturing was reported to be a method that involves suturing not only the mucosal layer, but also the submucosal layer. In this method, TTSCs are applied on the submucosal layer at the center of the ulcer to shrink the defect and suture the mucosa and submucosa together. We noticed that introducing reopenable clips enabled us to gently fold muscle layers as well as the submucosal layer. Making a few folded muscle layers allowed complete closure of even extremely large defects. This modified double layered suturing is like folding origami which is the Japanese traditional art of folding paper. We speculated that this method, origami method (OGM), achieved reliable closure of even large defects, like surgical suturing. This study aimed to evaluate the feasibility of OGM for colorectal post-ESD defects. Methods: This retrospective observational study was conducted at a tertiary care hospital. We reviewed the cases of OGM attempted after colorectal ESD at our institute between October 2021 and October 2022, and measured the clinical characteristics and outcomes of enrolled cases. Results: The OGM was attempted in 47 cases after colorectal ESD. Thirty-one cases (66%) were in the proximal colon; five (11%) in the distal colon; six (13%) in the upper rectum; and five (10%) in the lower rectum. The median resected specimen size was 38 mm, the largest being 85 mm. Complete closure was achieved in 44 cases (94%), including the largest case and all lower rectum cases. There were no perforations caused by clips during closure, and delayed perforation and bleeding were not observed. Conclusions: This new suturing method, like surgical all layer suturing, is feasible and recommended. The OGM could achieve reliable closure of large defects in any location, including the proximal colon and thick-walled lower rectum, using only TTSC.

Introduction:
The Endoscopic HeliX Tacking System (Apollo Endosurgery, Inc.) is a through-the-scope (TTS) suture-based device that has been gaining popularity in defect closure due to the ease of use and ability to close larger and irregular mucosal defects. The barbs are attached to a polypropylene suture and are able to be implanted into the submucosal/intramuscular space to allow for soft tissue approximation. In theory, these tacks were designed to not have full thickness penetration at any point of the gastrointestinal (GI) tract. We present the first reported case of a closed loop small bowel obstruction due to unintentional full thickness insertion of the X-Tack device during mucosal closure after large colon polyp resection.

Case:
A 65-year-old man with no significant medical history presented as a referral for consideration of a 2.5cm cecal sessile polyp removal. The subtle lesion was subsequently found on the inferior aspect of the appendiceal orifice. A lifting agent was applied, and an adequate cushion was created prior to resection. The polyp was removed in a piecemeal fashion with a mixture of hot snare and cold snare techniques. The edges were treated with argon plasma coagulation. The resection site was closed using the Endoscopic HeliX Tacking System with four tacks and a cinch and no extra tools were utilized. Histology returned as a sessile serrated polyp. The patient recovered well form the procedure with no immediate complications.

One month later, he presented to with severe, diffuse abdominal pain and abdominal distension. CT abdomen and pelvis revealed a closed loop distal small bowel obstruction. As a result, he was urgently taken to the operating room for laparoscopy. During laparoscopic evaluation, the barbs of the X-tack had full thickness penetration into the mesentery which led to the peritoneum being shifted down creating a hernia space that caused torsion and subsequent obstruction of the nearby small intestine, which had migrated. A successful small bowel resection and side to side functional end to end enteroenterostomy was performed and the patient did well afterwards.

Discussion:
In porcine models, X-tacks were utilized for closure of gastric and rectosigmoid perforations with high success and no reports of full thickness penetration of the barbs. However, there is limited data within the thinner walled areas of the GI tract. We present the first known reported case of a full thickness complication of the X-tack device with subsequent closed loop small bowel obstruction. While the X-tack device has expanded our capabilities for closing large mucosal defects, full thickness insertion of the device is possible in thin-walled areas of the GI tract, and this should be taken into consideration when choosing mucosal closure options.