Discussion

Colectomy with colorectal anastomosis is technically challenging, and repeat operative surgeries are sometimes unavoidable [8]. Risk factors for a dehiscence and leak are classified as extraperitoneal or intraperitoneal based on anastomosis. This is an unusual case of AD which has been treated successfully with the OverStitch assembly. In conventional settings, the management of anastomotic leaks is cumbersome, subjecting the patient to multiple surgeries and the subsequent increased risk for complications like intraabdominal adhesions [9]. Moreover, it requires adequate expertise to manage such cases surgically, and even in safe hands, there is an increase in the risk of complications, risk from anesthesia, increased time for postoperative recovery, and increase in analgesic use. This could also result in an increase in overall health care expenditure.

An increased risk for AD was seen in patients who had an ASA score ≥3, prolonged operative time (> 3 h), and rectal location of the disease [10]. Some of these determinants that influence outcomes of surgery need to be considered in perioperative decision-making to avert leakage. However, with the advent of novel accessories in endoscopy and an apt collaborative work of surgery with endoscopy, new avenues have opened up for the endoscopist.

CT scans have been found to be effective in identifying patients with anastomotic leaks, in 65–89% of all patients [2, 11]; while one study has shown that water-soluble enema is superior to CT imaging in delineating distal colonic anastomotic leaks [12]. A CT scan is not accurate enough to provide assurance of anastomotic integrity, and patient parameters with symptoms need to be considered. Randomized studies for identifying AD that can compare CT scans combined with rectal contrast enema versus water-soluble enema are warranted. Intraoperative colonoscopy is vital for the assessment of stapled anastomosis, as it can directly visualize the anastomosis line. In our case, we found CT was useful as it showed a collection as a result of which the case was referred for further colonoscopy evaluation. CT in this patient was done without rectal contrast, hence it might have perhaps failed to detect the leak.

The basic principles of leak management include the identification of the site of the leak, drainage of leaked contents, and disruption of the flow of intestinal fluids across the leak with diversion or closure [13]. Preparation of the lumen with APC at the perimeter of the leak site is recommended. Running interrupted sutures are usually performed in two to three layers. The OverStitch assembly is a USFDA-approved endoscopic suturing device. It has the ability to reload the suture without removing the endoscope, the ability to use tissue grasping accessories in the adjacent working channel, and a reliable depth of needle penetration. However, it is only compatible with doublechannel therapeutic endoscopes, it is large in size, and it has a limited field of view [14]. Suturing is difficult in the gastric fundus, duodenum, and colon. This becomes challenging in the colon where there is a limited working space and maneuverability of the scope, it also becomes difficult especially at bends or flexures, as it was present in our case.

Currently, there are not too many articles available on the use of this device for managing AD. Hence, a headto- head comparison is currently not feasible. Nevertheless, the OverStitch assembly has been widely used for 9 years to place stents within the gastrointestinal lumen and to perform closure of leaks and fistulas, which suggests that it can be safely used with good outcomes. The OverStitch assembly has been successfully used for the closure of iatrogenic esophageal perforations, stent fixation, mucosal defect closure, and stoma reduction after bariatric surgery [15, 16]. This device may be superior to endoclips in perforations, due to its ability to achieve full-thickness suturing and create an airtight closure [16].

Although the treatment of our patient was successful and the chosen technique appropriate, other options with different profiles in terms of safety, cost, and evidence are available; namely, but not limited to, endo-sponge application, placement of a covered self-expanding metal stent, over-the-scope clip (OTSC) positioning, and fibrin glue injection [17]. OTSC has a limited role in large perforations. There are various tips and tricks for managing postoperative challenges; however, every procedure has its own limitations and strengths. Primary anastomosis with diverting loop ileostomy appears to be a safe alternative to Hartmann’s procedure in emergent cases [18]. The primary treating surgeon felt that performing primary anastomosis with diverting ileostomy was appropriate in our patient at that point; alternatively, a two-stage Hartmann’s procedure could also have been performed.

Conclusion

Endoscopic suturing with the OverStitch device is an emerging technique for managing perforation and leaks. Although its use requires comprehensive training with a steep learning curve, it has the capability to mimic surgical closure in a minimally invasive manner. Due to the availability of limited data on its long-term use, further larger prospective and comparative studies are needed to define the role of endoscopic suturing devices in managing defects of the gastrointestinal tract.

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