The SAGES Manual of Flexible Endoscopy by Peter Nau & Eric M. Pauli & Bryan J. Sandler & Thadeus L. Trus

Author:Peter Nau & Eric M. Pauli & Bryan J. Sandler & Thadeus L. Trus
Language: eng
Format: epub
ISBN: 9783030235901
Publisher: Springer International Publishing

Both endoscopic suturing devices mount to the distal end of a gastroscope; the Overstitch is secured by an insert that applies pressure within the therapeutic channel of the endoscope while the Overstitch Sx is secured by two silastic straps that need to be tightened and then cut flush with the device using a scalpel. When mounted, the Overstitch has an outer diameter of 15.8 mm when closed and 23.3 mm when open. Despite mounting on smaller endoscopes, the Overstitch Sx has similar dimensions: a closed outer diameter between 15.4 and 16.4 mm (depending on the scope diameter it is mounted to) and 22.1 mm when open. Both devices extend well beyond the distal endoscope tip (18.4 mm for Overstitch and 19.8 mm for Overstitch Sx), and as such, many endoscopists elect to use an overtube with the device to prevent inadvertent damage from the rigid corners of the device.

The suturing handle mounts to the control section of the endoscope. Both devices include components that pass parallel to the endoscope insertion tube. The Overstitch has one cable that functions to open and close the swing arm. The Overstitch Sx device includes this cable, as well as two accessory channels used to deliver the needle exchange tool and the Helix tissue acquisition tool. The Overstitch suturing angle is fixed as the swing arm of the device always closes directly toward the therapeutic channel (i.e., suturing always occurs from 10–11 o’clock to 4–5 o’clock on the monitor). The Overstitch Sx is capable of being mounted in virtually any circumferential position on the endoscope tip, which permits the endoscopist to select the most efficient angle of suturing for the defect being managed. Once the Overstitch Sx is mounted on the cap it is quite difficult to rotate to a new position, so care must be careful not only in selecting the desired angle, but in affixing the device correctly at the chosen angle.

Defect closure with Overstitch devices require significantly more practice and skill than closure with over-the-scope clips, which are somewhat “fire and forget” in their application. There are several issues that make endoscopic suturing challenging: (1) the most efficient direction of closure must be selected, which is generally in a right-to-left fashion; (2) adequate tissue bites must be individually acquired, and it can take time to understand the haptic feedback that occurs as the needle passes through appropriate tissue bites; (3) the procedure generally takes longer as each tissue bite requires a multistage process (load the needle, acquire tissue via scope positioning or Helix grasper, close the swing arm to partly pass the needle through the tissue, pull the needle fully through the tissue with the exchange tool, open the swing arm, push suture slack through to let the device move away from the tissue, reload the needle); (4) the suture can become crossed on itself, or tangled in the swing arm which can be difficult to undo; (5) the monofilament suture can break.

Both devices secure tissue in a similar fashion; the needle

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