Common and Uncommon Problems During Endoscopic Suturing With Apollo Overstitch: Tips and Tricks for Troubleshooting

Background and Aims: The Apollo Endosurgery OverStitch is currently the most used endoscopic suturing device. Suturing techniques are still not fully standardized and their training does not often provide sufficient competence. Thus, several technical problems may occur, also due to engineering complexity of the suturing device. The experience of a high-volume Center is reported as to suggest tips and tricks for troubleshooting. Methods: A retrospective analysis was conducted on a prospectively collected database reporting patients treated with Apollo Endosurgery OverStitch between November 2014 and October 2020: Endoscopic Sleeve Gastroplasty (ESG), Transoral Outlet Reduction (TORe) of gastric by-pass, suturing of gastrointestinal fistulas or perforations and esophageal stents fixation were performed. Technical difficulties encountered were reviewed and their respective solutions were documented. Results: Out of a total of 393 suturing procedures, 252 ESG, 102 TORe, 23 suturing of fistulas or perforations, and 16 fixations of esophageal stents were realized. Breakage of the Suture Loading Tab occurred in 13% of the cases and misalignment between the needle driver and the anchor exchange was reported in 8.4% of the procedures. It happened respectively in 6.4% and in 0.2% of the cases that the thread made a loop behind the needle driver and that the needle driver blocked in the closed position. Tricks on how to manage these problematic situations and tips on how to simplify the suturing procedure are reported. Conclusions: During endoscopic suturing many issues can arise. Troubleshooting tricks and simplifying tips may help endoscopists in accelerating their learning curves and, thus, contribute to better outcomes of the procedures.