Kent C Sasse, MD, MPH, FACS, FACRS, David L Warner, BS. University of Nevada School of Medicine
Device Objective and Description: Gastric microperforation following bariatric surgical procedures is often treated with endoluminal esophagogastric stent placement. Stent migration is a common occurrence, reportedly occurring in 30 to 50% of stent placements following sleeve gastrectomy microleaks.
The use of an endoluminal suturing device (Apollo Overstitch) to secure the esophageal stent in place may be advantageous in the avoidance of serious complications of stent migration. The Overstitch is an FDA approved endoluminal suturing device, and has a wide variety of uses in surgery, but its use in esophageal stent placement has only recently been reported in literature. The enhanced accessibility and ease of use of the Overstitch makes it an ideal tool in the fixation of esophageal stents, which may reduce the likelihood of stent migration. A series of eight cases are presented herein of endoluminal stent placements for micro leaks following sleeve gastrectomy procedures. In the latter four cases, the Overstitch was used to secure the stent.
Preliminary Results: In the first case, a fully covered endoluminal stent was placed for treatment of a sleeve gastrectomy fistula, and the stent subsequently migrated into the jejunum causing jejunal perforation. In the next three cases, fully covered endoluminal stents were placed without additional suture fixation, and two of these stents subsequently migrated antegrade, requiring additional procedures. In the final four cases, fully covered endoluminal stents were placed with additional endoluminal suture fixation of the proximal stent to the esophageal wall using 2-0 absorbable suture and the Apollo Overstitch device. None of the four cases that utilized suture fixation subsequently migrated.
Future Directions: Endoluminal stent migration remains a common and vexing problem, often requiring repeat procedures to remedy the problem. In case one reported above, the patient experienced a serious complication of jejunal perforation following Stent migration. In an effort to prevent such complications, our practice turned to a procedure of suture fixation utilizing an endoluminal suture device technique (Apollo Overstitch).
Other authors have reported use of endoscopic clip placement and the use of partially covered stents in order to reduce stent migration. In our experience, the endoluminal suturing technique has proven successful and easy to perform. Considering the potential for very serious complications in this case series, and reports from other authors, we propose that endoluminal suturing be a potential standard of care for the placement of endoscopic esophageal stents.