Novel Endoscopic Strategy for Addressing Complex Gastrointestinal Defects via the X-Tack System: a retrospective single-center case series

Aims Endoscopic suturing (ES) has become a key method for managing gastrointestinal defects. The X-Tack System (Boston Scientific) is a novel, easy-to-use, through-the-scope (TTS) suture-based device that facilitates precise defect closure. Although designed for mucosal closure after endoscopic resections, the X-Tack System has also proven effective in treating complex gastrointestinal defects, especially after surgery. We aimed to report the feasibility and the follow-up outcomes of ES using the X-Tack System for different complex defects.

Methods We retrospectively identified thirteen cases that had undergone ES with X-Tack System at our Institution between January and September 2024. We collected baseline demographic and clinical data and procedural outcomes, including technical success and intra/post-procedural complications. Patients received a follow-up for reporting major complications and an update on clinical status.

Results Among the 13 cases, nine (69.2%) were male and four (30.8%) were female, with a median age of 57 (IQR: 48-67). The defects treated included small-bowel leaks (n=3; 23.1%), anastomotic dehiscence (n=6; 46.2%), post-ESD pararectal collection (n=1; 7.7%), colonic fistula (n=1; 7.7%), esophageal-pleural fistula (n=1; 7.7%), and Boerhaave syndrome (n=1; 7.7%). The median Charlson Comorbidity Index (CCI) was 5 (IQR: 3-5). The median defect width was 10 mm (IQR: 8-20), and in nine out of 13 cases the wall condition was unhealthy (inflamed layers and edematous mucosa with irregular margins). The endoscopic closure was technically successful in all cases, with a median procedure time of 25.0 minutes (IQR: 18-40). We used a therapeutic gastroscope with short-system in 10 cases, a standard colonoscope with long-system in 2 cases and a double-ballon enteroscope with long-system in the remained case. No intra- or post-procedural complications occurred. Fluoroscopy was necessary just in 7 cases to confirm the effective suturing closure at procedure’s end. Ten patients (76.9%) exhibited clinical remission seven days after the procedure, confirmed by imaging and laboratory tests. 2 cases (15.5%) achieve clinical success after an additional endoscopic session after 7-days (1 case by ES with X-tack (1) and one by an anti-migration esophageal stent). In latter case (7,6%), the critically-ill patient presented a large colonic fistula with esophageal-jejunal leak and an abdominal abscess following gastrectomy: she died 4-weeks later in ICU department due to septic shock. At the end of the follow-up period [2.0 months (IQR: 2-4)], no clinical or radiological recurrence was observed in the remaining ten cases.

Conclusions ES with the X-Tack System demonstrated high technical success and a favorable safety profile in closing various gastrointestinal defects. The system was particularly effective even in challenging cases, such as those with unhealthy surrounding tissue. Our findings support the utility of the X-Tack System in treating complex gastrointestinal complications, especially in post-surgical settings.

 

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Conflicts of Interest

Roberto Di Mitri is a consultan for Boston ScientificSandro Sferrazza is a consultant for Olympus

Publication History

Article published online:
27 March 2025