Through-the-scope tack and suture system for closure of a large iatrogenic rectal perforation

Early closure of an iatrogenic gastrointestinal defect reduces related adverse events. The closure method depends on the size and location of the defect [1] [2]. Delayed closure may complicate treatment.

Our patient was a 68-year-old man with sepsis secondary to iatrogenic perforation of the lower rectum during a Bricker-type cystectomy for bladder carcinoma T2N0M0. During surgery, the anterior rectal wall was accidentally perforated and sutured in the same act. The patient did not recover well after the operation (clinical and lab evaluations). On the 10th postoperative day, persistent rectal perforation was confirmed by computed tomography (CT). The patient was reoperated on to suture the rectal lesion, but without success, and a loop colostomy was performed. A further 7 days later his clinical condition had worsened, with hemodynamic changes and sepsis. Repeat CT demonstrated persistence of the perforation and a large air–fluid level at the left lateroconal fascia, requiring percutaneous drainage. A colonoscopy was performed and showed abundant fecal remains in the rectal ampulla. A 35-mm orifice was observed at 3 cm from the anal margin, connecting with the peritoneal cavity with abundant purulent and fecaloid content. Inside the cavity, a surgical drainage catheter was visualized and was relocated under endoscopic vision until it drained the collection. As peritoneal communication contraindicates endoscopic placement of a vacuum system, a fully covered 20 mm × 10 cm stent (Niti-S Enteral Colonic Covered Stent; Taewoong Medical) was inserted with its distal end outside the anal margin. Ten days later, the stent was removed. The perforation edges had matured ([Fig. 1]), so we treated them with argon and sutured them using a novel endoscopic suturing device: 4 through-the-scope tack device kits (X-Tack Endoscopic HeliX Tacking System; Boston Scientific) ([Video 1]). Complete closure of the perforation was achieved. After this procedure, the patient had a favorable outcome, without associated rectal tenesmus. After 2 days, he was discharged.

Fig. 1 Iatrogenic rectal perforation in a 68-year-old man.

Through-the-scope tack and suture system used to repair a large iatrogenic rectal perforation.Video 1

X-Tack is a simple, useful, and accessible suture method with a low complication rate, and is a minimally invasive alternative to surgery, enabling the closure of large iatrogenic gastrointestinal perforations [3].

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Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Canakis A, Deliwala SS, Frohlinger M. et al. Endoscopic outcomes using a novel through-the-scope tack and suture system for gastrointestinal defect closure: a systematic review and meta-analysis. Endoscopy 2024; 56: 605-611
• 2 De Cristofaro E, Lafeuille P, Rivory J. et al. Large defect closure using a helix tacking system and endoclips after endoscopic submucosal dissection of two adjacent colonic lesions. Endoscopy 2024; 56: E443-E444
• 3 Ebigbo A, Wanzl J, Afify S. et al. Endoscopic suture-based closure of a dehiscent rectal stump. Endoscopy 2024; 56: E381

Publication History

Article published online:
11 February 2025