Entanglement of an over-the-scope full-thickness endoscopic suturing device during stent fixation: a case series of adverse events and rescue strategies.

Background and Aims: Esophageal fully covered self-expandable metal stents (FCSEMSs) and lumen-apposing metal stents are used for the management of strictures and luminal defects. Stent fixation can minimize stent migration risk, and endoscopic suturing is an effective option. Here, we describe an adverse event of over-the-scope endoscopic suturing device entanglement during stent fixation and discuss rescue maneuvers. Methods: Three experienced advanced endoscopists performed 5 cases of stent fixation with an over-the-scope endoscopic suturing device. Results: Esophageal through-the-scope FCSEMSs were placed in 3 patients; all had previous radiation. During stent fixation, the needle driver was caught on the stent, out of the field of view. An argon plasma coagulator with a second endoscope inserted adjacently was used to free the stent in 2 cases; in the third case, forceful handle separation with the device outside the patient facilitated stent release. In 2 gastric cases, stents (FCSEMSs and lumen-apposing metal stents) in the stomach were disentangled using rat-tooth forceps. Conclusions: Over-the-scope suturing device entanglement with FCSEMSs is possible and can occur outside the field of view. Reduced esophageal wall compliance caused by radiation and the use of more-flexible through-the-scope stents may have contributed to this adverse event. Rescue maneuvers for entanglement include argon plasma coagulation of the stent wire, rat-tooth forceps, and forceful handle separation.