Looking beyond immediate success: unexpected challenges in the removal of novel suturing systems

Abstract

Figures

X-Tack and TTS clips placed after colonic ESD. Abbreviations: ESD, endoscopic submucosal dissection; TTS, through-the-scope.

X-Tack anchor still embedded in colonic mucosa at 12-month follow-up.

Full text

Closure of defects after endoscopic submucosal dissection (ESD) is a routine practice to prevent complications. Conventional through-the-scope (TTS) clips are typically effective for closing linear defects up to 2 cm in size 1 . For larger defects, over-the-scope clips can be used, although their placement may hinder the use of additional closure devices 2 . To address these limitations, new suturing systems are being developed to facilitate closure after extensive ESD. Among these, the X-Tack Endoscopic HeliX Tacking System is a novel TTS device designed for soft tissue approximation and is compatible with standard gastroscopes and colonoscopes 3 .

We recently demonstrated its feasibility in closing large post-ESD defects using a combination of X-Tack and TTS clips 4 , but limited data are available on its removal, especially in patients needing mucosal surveillance.

We present the follow-up colonoscopy of a 69-year-old man with ulcerative colitis, previously treated with ESD of two adjacent lesions in the sigmoid colon (February 2024). The mucosal defect was closed using a combination of X-Tack and TTS clips ( Fig. 1 ).

X-Tack and TTS clips placed after colonic ESD. Abbreviations: ESD, endoscopic submucosal dissection; TTS, through-the-scope.

Twelve months later, a follow-up surveillance colonoscopy revealed multiple flat subcentimetric lesions in the left colon, which were resected en bloc using a cold snare. The X-Tack system was still present, with one helix anchor embedded in the mucosa ( Fig. 2 ). To ensure complete inspection of the area, device removal was attempted. Initial removal with forceps failed. It was eventually removed using a cold snare, though with technical difficulty. A small muscularis propria injury occurred, which was successfully closed with TTS clips ( Video 1 ).

X-Tack anchor still embedded in colonic mucosa at 12-month follow-up.

Challenging removal of novel endoscopic suturing device.Video 1

This case highlights the challenges of removing anchored closure systems, especially when surveillance is required. While effective for closure, the X-Tack system may pose technical risks during removal. Careful techniques and further studies are needed to evaluate safe removal strategies across different clinical scenarios.

Endoscopy_UCTN_Code_CPL_1AJ_2AJ