Pledget Reinforcement of Endoscopic Suturing Endoscopic full-thickness suturing has allowed for broad applications including defect closure, stent fixation, bariatric and anti-reflux procedures. Suture durability contributes significantly to long-term tissue remodeling, and suture failure is associated with weight regain and poor durability for bariatric procedures. Endoscopic suture failure is an issue. A follow-up of endoscopic bariatric procedures has revealed that delayed suture or mucosal failure tends to occur at the interface between the tissue anchors and gastric mucosa or at high tension points between distant approximated tissues, sometimes called cheese wiring. This phenomenon is visible endoscopically and has been associated with weight regain. This is a 31-year-old female with a history of obesity, BMI 37.8, and NASH, Refractory to Lifestyle Modification and GLP-1 Agonist Therapy. She elected to undergo endoscopic sleeve gastroplasty, and we utilized a U-pattern with reinforcing interrupted sutures. Commercially available surgical pledges were added to reinforcing sutures to spread suture tension and preserve gastric tissue and suture remodeling. Here we see an example of an endoscopic sleeve gastroplasty that was performed five years earlier. Several areas of mucosal scarring suggestive of suture rupture through the gastric mucosa or cheese wiring are seen. Additionally, we can see clearly submucosally embedded suture cinches and tissue anchors. The shape of the sleeve is no longer restrictive, and this patient had weight regain. Here we see an endoscopic revision of gastric bypass performed at an outside institution using an interrupted pattern. This is a high-tension pattern that we do not use, and the suture has clearly failed. Here we are performing the pledget-reinforced endoscopic sleeve gastroplasty. Tissue bites are taken as per usual, and after the reinforcing stitch is completed, both ends of the suture are removed from the patient. Note the closed arm of the suturing device to facilitate suture removal. The suture is then released, and the Teflon pledgets are advanced onto the suture. Given the toughness of the Teflon material, a 16-gauge needle is used to pierce it, and the endoscopic tissue anchor is advanced through the hole. Gentle tension is then placed on the opposite end of the suture, and the pledget is advanced with the tissue anchor back into the patient until resistance is felt at the mucosa. A second Teflon pledget is then placed onto the trailing end of the suture in a similar fashion. The pledget is advanced along the suture and back into the patient. The endoscope is then used to advance the pledget to the mucosal surface, but first the suture must be recaptured through the endoscopy working channel. The forceps are used to grasp the suture and pull it through the length of the endoscope. Here we see the endoscope being placed back into the patient with gentle tension placed on the end of the suture. This facilitates advancement of the pledget. Here we see the final advancement of the pledget using a standard suture cinch. The pledgets appear quite large endoscopically, especially in comparison to the standard endoscopic tissue anchors. Here we see the two areas of mucosa being approximated and the suture cinch being deployed. The reinforcing suture with pledget reinforcement is now completed. The endoscopic sleeve gastroplasty was completed in 75 minutes without complication. The patient was discharged on the same day with oral Tylenol and Ondansetron for pain and nausea. At follow-up one month later she was asymptomatic and had lost 8% of her total body weight. Pledgets have many potential clinical implications when used endoscopically. Improved suture durability may improve weight loss and durability of endoscopic tissue remodeling procedures such as endoscopic sleeve gastroplasty. If this is effective, the long-term cost benefit of endoscopic bariatric and metabolic therapies may be improved significantly. Additionally, novel, simpler, and potentially faster suture patterns may be facilitated by pledget reinforcement, allowing for more aggressive approximation. In conclusion, reinforcement of endoscopic sutures with surgical pledgets is technically feasible and did not add significantly to procedure time or patient symptoms. Real placement, pledget size, and long-term outcomes remain undetermined, though clinical and laboratory studies are ongoing.

endoscopic suture failure

bariatric procedures

weight regain

pledget reinforcement

endoscopic sleeve gastroplasty