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BACKGROUND: Endoscopic repair of the perforated gut has been reported in rare cases. Various techniques have been used to close the gut perforations via an endoscope. We describe three cases of endoscopic repair of oesophageal and gastric perforations using an endoscopic sewing machine. CASE 1: A 54 year old man had a partial gastrectomy for gastric cancer. A postoperative fistulous leak between the gastrojejunostomy and the chest was demonstrated by contrast study. Six stitches were placed to close the leak using the endoscopic sewing machine. Post procedure contrast x-ray showed that the leak had sealed. CASE 2: A 70 year old man with carcinoma of the oesophagus had a distal oesophageal perforation during Savary dilatation. Three stitches were placed with endoscopic sewing machine to close the perforation. A repeat contrast study showed no leak. Patient died three months later in hospital due to unrelated causes. CASE 3: A 54 year old man with lymphoma of the oesophagus and stomach developed a fistula between the oesophagus and the mediastinum. Covered metal stents were placed twice previously and had fallen into the stomach. A covered Z stent [Wilson Cook] was sewn to the oesophagus using the endoscopic sewing machine. The stent remained in position and the fistula healed nicely. The patient who had been in the intensive care unit for three months was able to leave intensive care unit. CONCLUSION: Successful closure of the gut perforations was possible using endoscopic sewing machine.

Aim : The aim of this study was review the results of endoscopic gastroplasty in a series of patients. Methods : Endoscopic Gastroplasty was performed at flexible endoscopy in 102 patients with Gastroesophageal Reflux Disease uncontrolled by long-term medical therapy and who were offered and declined anti-reflux surgery (open or laparoscopic) or were deemed unfit for general anesthesia due to concurrent illness. GERD was confirmed by preoperative manometry and 24 hour ambulatory pH studies. Using a 9mm diameter endoscopic sewing machine a neo-esophagus of 1-2 cm was created below the cardio-esophageal junction by placing sutures and securing the tissue with 4 half-hitches tied extracorporeally. Results : The operation was performed as a day-case procedure under sedation and the median duration of the procedure was 35 minutes. Post-operative assessment was made at a median of 12 weeks (8-52) with respect to symptoms, manometry and 24 hour ambulatory pH studies. Symptoms assessed by DeMeester symptom score improved from a median of 5 to 1 [p<0.05]. Median lower esophageal sphincter length increased from 2 to 3 cm [p<0.05] and pressure increased from 5 to 8 mm Hg [p<0.05]. The median % time pH < 4 decreased from 8.4 to 2.7 [p<0.05]. The majority of patients were satisfied with the result. There was a highly significant reduction in the use of proton pump inhibitor drugs following treatment. Complications included minor haematemesis in two patients, transient dysphagia in 3, one patient was oversedated and required endotracheal intubation, in one patient with thoracogastric adhesions following thoracoplasty the endoscopic stitches cut out and a surgical Nissen fundoplication was performed. Results were less good in patients with hiatus hernia greater than 2 cm and patients with sensitive oesophagus. Clinical and endoscopic follow up suggests that most patients with good improvement maintain that improvement at 2-4 years and their stitches are usually still present. Repeat pH measurments at 1,2,and 3 years post procedure in 2 patients showed no reflux.. Conclusion : In this series, endoscopic gastroplasty significantly improved symptoms, reduced acid reflux., and increased sphincter length and pressure. Potential advantages of this procedures include easy repeatability, reversibility, short operation time, lack of need for general anesthesia. Endoscopic gastroplasty has a short term efficacy comparable to operative fundoplication, but with a much lower utilization of health care resources.

Background: Submucosal [SM] resection allows small mucosal or SM tumors to be removed from stomach, esophagus and colon at modest risk of perforation. The availability of a method to oversew a perforation with endoscopic sewing machine [ESM} subsequent to SM resection might make this method safer. Methods: Bands were applied to gastric tissue using a band ligating device and the resulting polyp was resected using coagulative diathermy applied through a snare. SM injection was compared with no SM injection. Using post mortem porcine gastric and esophageal tissue a series of full thickness holes of 5-25 mm were cut using a scalpel. The hole was closed until watertight with stitches placed using an ESM with 3.0 nylon thread and knots tied with an endoscopic knot pusher. Based on these bench experiments, three live pig experiments were performed. An area in the body of the stomach was raised with 4 ml of normal saline injected via an endoscopic injection needle. The area was then converted into a polyp using a band ligation device. The polyp was 1.8 cm in diameter. Two stitches were applied on each side of the polyp using ESM. The stitches were left untied. The resection of the polyp was performed by using a snare diathermy. The mucosal defect was 2.5cm. No overt perforation was noted. The sutures were tied and cut using tying and cutting device. There was no perforation. The pig recovered uneventfully and survived. Results: 9/10 band polyp resections without preinjection caused small perforations compared to 1/10 with preinjection of 1-5ml of saline. The size of these perforations was 5-7mm. A single thread sewn either side of the resection margin was a more efficient method to close wounds. Holes closed = 12; median hole size 2.25 mm; total number of stitches = 33; total number of knots = 21; total number of half hitches = 84. Two stitches closed holes up to 5 mm, more stitches were required for larger holes. Excision of wide based and flat lesions was successful and safe in pig stomach. Conclusions: 1. Polypectomy of banded gastric tissue without prior saline injection caused perforations. 2. Preinjection with saline reduced the incidence of perforation. 3 Large gastrointestinal lesions can be excised safely by using stitched closure of the potential perforation with Endoscopic Sewing Machine suturing.