Case Report: A 58-year-old woman underwent multivisceral transplantation (liver, pancreas, intestine, and stomach with gastro-gastric reconstruction) for ultrashort bowel syndrome due to intestinal ischemia following complications from resection of a symptomatic duodenal cyst, which led to multiple subsequent electrolyte and nutritional complications. Eight days after surgery, the patient developed fistulization of the gastric suture documented on CT, initially managed conservatively with complete bowel rest and percutaneous drainage. After 10 days without improvement and with radiologic confirmation of an approximately 5 cm gastro-gastric anastomotic dehiscence, endoscopic vacuum therapy with sponge placement (EVT) was initiated. Over 50 days, 13 sponge exchanges were performed, with an incomplete response and persistence of a fistulous tract up to 25 mm in maximal diameter. Given the patient’s instability and severe post-transplant complications, surgical reintervention was deemed unfeasible. Therefore, endoscopic suturing was attempted to close the defect, first refreshing the fistulous edges with argon plasma coagulation (60 W, 1.2 L/min) to promote healing. The entire discontinuity was closed using a single 2-0 polypropylene suture in a continuous Z-pattern, supplemented by 2 hemostatic clips placed at one margin. Subsequent radiologic and endoscopic follow-up demonstrated complete closure of the dehiscence without complications, despite being closed two months after its onset — a factor typically associated with reduced efficacy.

Discussion: Anastomotic dehiscence is a common postoperative complication in gastro-gastric anastomoses. EVT is currently considered the first-line management for dehiscence at this level. However, failure rates of up to 20% have been reported when used as monotherapy, requiring access to alternative therapeutic options. Full-thickness endoscopic suturing systems enable the placement of transmural sutures that provide robust tissue approximation without requiring surgical intervention [1]. These systems are currently approved for bariatric procedures, as well as for postoperative defects closure, with early diagnosis being a key factor in improving clinical success [2]. Our case highlights the role of these systems as a rescue therapy even in chronic defects, particularly in poor surgical candidates. Limited number of targeted studies and requirement for specialized training remain barriers to their broader implementation in high-volume centers.

Conclusions: Endoscopic suturing shows promising outcomes for the closure of mural defects such as gastro-gastric anastomotic dehiscence and may be particularly useful in high volume units of complex surgical cases. Comparative studies against EVT, as well as specialized training programs, are needed to expand the reach and clinical adoption of this technique.