LAUSR

A 56-year-old man with a walled-off necrosis (WON) underwent endoscopic necrosectomy using a lumen-apposing metal stent (LAMS) (Hot Axios; Boston Scientific, Boston, Massachusetts, USA) (▶Fig. 1 a), which improved the abdominal inflammation within 1 month. However, 1 year after removal of the LAMS, the WON relapsed with abdominal pain and elevated C-reactive protein (CRP) levels. Gastroscopy revealed that the fistula caused by the LAMS placement persisted, with leakage of necrotic material. Fluoroscopy also revealed a colonic fistula associated with the WON in the sigmoid colon (▶Fig. 1b). An ileostomy, in combination with drainage using a plastic stent into the WON and administration of antibiotics, failed to improve abdominal symptoms and normalize CRP levels; this was suggested to be attributed to the two fistulas. After percutaneous drainage of the WON, an over-the-scope (OTS) clip was applied to close these fistulas. However, the colon and gastric tissues around the fistula were too rigid to be pulled in the OTS clip. In this situation, we attempted to close the gastric fistula using a new endoscopic hand-suturing device (SutuArt; Olympus, Tokyo, Japan) and a suture needle with thread (V-lock; Medtronic, Dublin, Ireland) after cauterization of the gastric mucosa surrounding the fistula to promote wound healing (▶Fig. 1 c–g, ▶Video 1). One month later, the fistula was completely fixed with a normal covered mucosa (▶Fig. 1 h). This led to an improvement in abdominal pain and CRP levels. Usually, LAMS-associated fistulas are closed in their natural course [1–3]. We encountered a rare case in which a longterm remaining fistula resulted in WON relapse, which was successfully treated by closing the fistula using a new endoscopic suturing device. This hand-suturing device is a good option for closing LAMS-associated fistulas.