1
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Egami Y, Sugimura K, Masuzawa T, Katsuyama S, Takeda Y, Murata K. Successful treatment of an anastomotic leakage after total gastrectomy using a fully covered self-expandable metal stent with an anchoring thread: A case report. Int J Surg Case Rep 2024; 115:109224. [PMID: 38181655 PMCID: PMC10809106 DOI: 10.1016/j.ijscr.2024.109224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 12/28/2023] [Accepted: 01/02/2024] [Indexed: 01/07/2024] Open
Abstract
INTORODUCTION AND IMPORTANCE The incidence of anastomotic leakage in the esophagojejunostomy after total gastrectomy is a serious complication of this procedure. Here, we report a case in which a fully covered stent was endoscopically placed into a fistula caused by anastomotic leakage after total gastrectomy. CASE PRESENTATION An 88-year-old man diagnosed with advanced gastric cancer had tumor invasion close to the esophagogastric junction. We performed a laparoscopic total gastrectomy and Roux-en-Y reconstruction. On postoperative day (POD) 3, the patient experienced septic shock due to anastomotic leakage and subsequent mediastinitis. Mediastinal irrigation and drainage under laparotomy were performed. Sepsis improved with drainage, but the fistula persisted due to anastomotic leakage. CLINICAL DISCUSSION Based on a diagnosis of refractory fistula, a fully covered self-expandable metal stent (HANAROSTENT® Esophagus) was inserted POD 21 using esophagoscopy. To prevent stent migration, a 3-0 silk thread was attached to the ostial side of the stent and fixed at the nose. The stent was endoscopically removed 36 days. Esophagoscopy after stent removal revealed that the fistula had resolved and that the anastomotic leakage had healed. The patient started oral intake and was discharged home. CONCLUSION This case demonstrates the potential for use of a fully covered self-expandable metal stent with an anchoring thread for anastomotic leakage after total gastrectomy for gastric cancer.
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Affiliation(s)
- Yosuke Egami
- Department of Gastroenterological Surgery, Kansai Rosai Hospital, 3-1-69, Inabaso, Amagasaki city, Hyogo 660-8511, Japan
| | - Keijiro Sugimura
- Department of Gastroenterological Surgery, Kansai Rosai Hospital, 3-1-69, Inabaso, Amagasaki city, Hyogo 660-8511, Japan.
| | - Toru Masuzawa
- Department of Gastroenterological Surgery, Kansai Rosai Hospital, 3-1-69, Inabaso, Amagasaki city, Hyogo 660-8511, Japan
| | - Shinnsuke Katsuyama
- Department of Gastroenterological Surgery, Kansai Rosai Hospital, 3-1-69, Inabaso, Amagasaki city, Hyogo 660-8511, Japan
| | - Yutaka Takeda
- Department of Gastroenterological Surgery, Kansai Rosai Hospital, 3-1-69, Inabaso, Amagasaki city, Hyogo 660-8511, Japan
| | - Kohei Murata
- Department of Gastroenterological Surgery, Kansai Rosai Hospital, 3-1-69, Inabaso, Amagasaki city, Hyogo 660-8511, Japan
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2
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Aourarh B, Souadka A, Majbar MA, Benkabbou A, Chakkor A, Bakkar M, Mohsine R, Amrani L. Endoscopic management of anastomotic leakage after colorectal cancer surgery in a Moroccan center: A case series and literature review. SAGE Open Med Case Rep 2023; 11:2050313X231205716. [PMID: 37954544 PMCID: PMC10637152 DOI: 10.1177/2050313x231205716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/19/2023] [Indexed: 11/14/2023] Open
Abstract
Endoscopic management has become an alternate treatment to a revision surgery for colorectal fistulas. Eight patients who were treated by endoscopy for postoperative anastomotic leakage to colorectal cancer were included. A univariate analysis was carried out to determine the predictive factors of success. All our patients were treated using metallic clips. The primary efficiency of this technique was 50%. In a univariate analysis, the size of the fistula and its distance from the anal margin had an influence on the efficiency of the endoscopic treatment, which was not the case for either the surgical technique or the use of neoadjuvant radiotherapy. This endoscopic treatment is effective and represents a more secure alternative than revision surgery. In our study, the use of metallic clips showed a 50% success rate, going up to 100% for the group of patients with a fistula ostium of a size ⩽1 cm, proving the necessity of using this technique.
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Affiliation(s)
- Benayad Aourarh
- Surgical Oncology Department, National Institute of Oncology, University Mohammed V in Rabat, Rabat, Morocco
| | - Amine Souadka
- Surgical Oncology Department, National Institute of Oncology, University Mohammed V in Rabat, Rabat, Morocco
| | - Mohamed Anass Majbar
- Surgical Oncology Department, National Institute of Oncology, University Mohammed V in Rabat, Rabat, Morocco
| | - Amine Benkabbou
- Surgical Oncology Department, National Institute of Oncology, University Mohammed V in Rabat, Rabat, Morocco
| | - Amal Chakkor
- Surgical Oncology Department, National Institute of Oncology, University Mohammed V in Rabat, Rabat, Morocco
| | - Meriem Bakkar
- Surgical Oncology Department, National Institute of Oncology, University Mohammed V in Rabat, Rabat, Morocco
| | - Raouf Mohsine
- Surgical Oncology Department, National Institute of Oncology, University Mohammed V in Rabat, Rabat, Morocco
| | - Laila Amrani
- Surgical Oncology Department, National Institute of Oncology, University Mohammed V in Rabat, Rabat, Morocco
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3
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Mun EJ, Wagh MS. Recent advances and current challenges in endoscopic resection with the full-thickness resection device. World J Gastroenterol 2023; 29:4009-4020. [PMID: 37476589 PMCID: PMC10354579 DOI: 10.3748/wjg.v29.i25.4009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 03/27/2023] [Accepted: 06/05/2023] [Indexed: 06/28/2023] Open
Abstract
Endoscopic full-thickness resection (EFTR) has emerged as a viable technique in the management of mucosal and subepithelial lesions of the gastrointestinal tract (GIT) not amenable to conventional therapeutic approaches. While various devices and techniques have been described for EFTR, a single, combined full-thickness resection and closure device (full-thickness resection device, FTRD system, Ovesco Endoscopy AG, Tuebingen, Germany) has become commercially available in recent years. Initially, the FTRD system was limited to use in the colorectum only. Recently, a modified version of the FTRD has been released for EFTR in the upper GIT as well. This review provides a broad summary of the FTRD, highlighting recent advances and current challenges.
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Affiliation(s)
- Elijah J Mun
- Division of Gastroenterology, University of Colorado School of Medicine, Aurora, CO 80045, United States
| | - Mihir S Wagh
- Interventional Endoscopy, Division of Gastroenterology, University of Colorado School of Medicine, Aurora, CO 80045, United States
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4
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Khadem S, Herzberg J, Honarpisheh H, Jenner RM, Guraya SY, Strate T. Safety profile of a multimodal fail-safe model to minimize postoperative complications in oncologic colorectal resections-a cohort study. Perioper Med (Lond) 2023; 12:5. [PMID: 36906563 PMCID: PMC10007828 DOI: 10.1186/s13741-023-00291-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 02/07/2023] [Indexed: 03/13/2023] Open
Abstract
BACKGROUND Despite innovations in surgical techniques, major complications following colorectal surgery still lead to a significant morbidity and mortality. There is no standard protocol for perioperative management of patients with colorectal cancer. This study evaluates the effectiveness of a multimodal fail-safe model in minimizing severe surgical complications following colorectal resections. METHODS We compared major complications in patients with colorectal cancers who underwent surgical resections with anastomosis during 2013-2014 (control group) with patients treated during 2015-2019 (fail-safe group). The fail-safe group had preoperative bowel preparation and a perioperative single dose of antibiotics, on-table bowel irrigation and early sigmoidoscopic assessment of anastomosis in rectal resections. A standard surgical technique for tension-free anastomosis was adapted in the fail-safe approach. The chi-square test measured relationships between categorical variables, t-test estimated the probability of differences, and the multivariate regression analysis determined the linear correlation among independent and dependent variables. RESULTS A total of 924 patients underwent colorectal operations during the study period; however, 696 patients had surgical resections with primary anastomoses. There were 427 (61.4%) laparoscopic and 230 (33.0%) open operations, while 39 (5.6%) laparoscopic procedures were converted. Overall, the rate of major complications (Dindo-Clavien grade IIIb-V) significantly reduced from 22.6% for the control group to 9.8% for the fail-safe group (p < 0.0001). Major complications mainly occurred due to non-surgical reasons such as pneumonia, heart failure, or renal dysfunction. The rates of anastomotic leakage (AL) were 11.8% (22/186) and 3.7% (n = 19/510) for the control and fail-safe groups, respectively (p < 0.0001). CONCLUSION We report an effective multimodal fail-safe protocol for colorectal cancer during the pre-, peri-, and postoperative period. The fail-safe model showed less postoperative complications even for low rectal anastomosis. This approach can be adapted as a structured protocol during the perioperative care of patients for colorectal surgery. TRIAL REGISTRATION This study was registered in the German Clinical Trial Register (Study ID: DRKS00023804 ).
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Affiliation(s)
- Shahram Khadem
- Department of Surgery, Krankenhaus Reinbek St. Adolf-Stift, Hamburger Strasse 41, 21465, Reinbek, Germany
| | - Jonas Herzberg
- Department of Surgery, Krankenhaus Reinbek St. Adolf-Stift, Hamburger Strasse 41, 21465, Reinbek, Germany.
| | - Human Honarpisheh
- Department of Surgery, Krankenhaus Reinbek St. Adolf-Stift, Hamburger Strasse 41, 21465, Reinbek, Germany
| | - Robert Maximilian Jenner
- Department of Surgery, Krankenhaus Reinbek St. Adolf-Stift, Hamburger Strasse 41, 21465, Reinbek, Germany
| | - Salman Yousuf Guraya
- Clinical Sciences Department, College of Medicine, University of Sharjah, P. O. Box 27272, Sharjah, United Arab Emirates
| | - Tim Strate
- Department of Surgery, Krankenhaus Reinbek St. Adolf-Stift, Hamburger Strasse 41, 21465, Reinbek, Germany
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5
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Meier B, Wannhoff A, Denzer U, Stathopoulos P, Schumacher B, Albers D, Hoffmeister A, Feisthammel J, Walter B, Meining A, Wedi E, Zachäus M, Pickartz T, Küllmer A, Schmidt A, Caca K. Over-the-scope-clips versus standard treatment in high-risk patients with acute non-variceal upper gastrointestinal bleeding: a randomised controlled trial (STING-2). Gut 2022; 71:1251-1258. [PMID: 35321938 DOI: 10.1136/gutjnl-2021-325300] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 02/26/2022] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Acute non-variceal upper gastrointestinal bleeding (NVUGIB) is managed by standard endoscopic combination therapy, but a few cases remain difficult and carry a high risk of persistent or recurrent bleeding. The aim of our study was to compare first-line over-the-scope-clips (OTSC) therapy with standard endoscopic treatment in these selected patients. DESIGN We conducted a prospective, randomised, controlled, multicentre study (NCT03331224). Patients with endoscopic evidence of acute NVUGIB and high risk of rebleeding (defined as complete Rockall Score ≥7) were included. Primary endpoint was clinical success defined as successful endoscopic haemostasis without evidence of recurrent bleeding. RESULTS 246 patients were screened and 100 patients were finally randomised (mean of 5 cases/centre and year; 70% male, 30% female, mean age 78 years; OTSC group n=48, standard group n=52). All but one case in the standard group were treated with conventional clips. Clinical success was 91.7% (n=44) in the OTSC group compared with 73.1% (n=38) in the ST group (p=0.019), with persistent bleeding occurring in 0 vs 6 in the OTSC versus standard group (p=0.027), all of the latter being successfully managed by rescue therapy with OTSC. Recurrent bleeding was observed in four patients (8.3%) in the OTSC group and in eight patients (15.4%) in the standard group (p=0.362). CONCLUSION OTSC therapy appears to be superior to standard treatment with clips when used by trained physicians for selected cases of primary therapy of NVUGIB with high risk of rebleeding. Further studies are necessary with regards to patient selection to identify subgroups benefiting most from OTSC haemostasis. TRIAL REGISTRATION NUMBER NCT03331224.
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Affiliation(s)
- Benjamin Meier
- Gastroenterology, Klinikum Ludwigsburg, Ludwigsburg, Germany
| | | | - Ulrike Denzer
- Gastroenterology, University of Marburg, Marburg, Germany
| | | | | | - David Albers
- Gastroenterology, Elisabeth-Krankenhaus-Essen, Essen, Germany
| | | | | | | | - Alexander Meining
- Gastroenterology, University of Ulm, Ulm, Germany.,Gastroenterology, University of Würzburg, Würzburg, Germany
| | - Edris Wedi
- Gastroenterology, Sana Klinikum Offenbach, Offenbach, Germany.,Gastroenterology, University of Göttingen, Göttingen, Germany
| | - Markus Zachäus
- Gastroenterology, Helios Park-Klinikum Leipzig, Leipzig, Germany
| | - Tilman Pickartz
- Gastroenterology, University of Greifswald, Greifswald, Germany
| | - Armin Küllmer
- Gastroenterology, University of Freiburg, Freiburg im Breisgau, Germany
| | - Arthur Schmidt
- Gastroenterology, University of Freiburg, Freiburg im Breisgau, Germany
| | - Karel Caca
- Gastroenterology, Klinikum Ludwigsburg, Ludwigsburg, Germany
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6
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Wang Q, Wang F, Wang S, Hua H. Application of endoscopic mucosal advancement in the treatment of chronic anastomotic leakage: A case report. LAPAROSCOPIC, ENDOSCOPIC AND ROBOTIC SURGERY 2022. [DOI: 10.1016/j.lers.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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7
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Leeds IL, Sklow B. Through the Looking Glass: Endoscopic management of anastomotic leaks. SEMINARS IN COLON AND RECTAL SURGERY 2022. [DOI: 10.1016/j.scrs.2022.100885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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8
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Degiuli M, Elmore U, De Luca R, De Nardi P, Tomatis M, Biondi A, Persiani R, Solaini L, Rizzo G, Soriero D, Cianflocca D, Milone M, Turri G, Rega D, Delrio P, Pedrazzani C, De Palma GD, Borghi F, Scabini S, Coco C, Cavaliere D, Simone M, Rosati R, Reddavid R. Risk factors for anastomotic leakage after anterior resection for rectal cancer (RALAR study): A nationwide retrospective study of the Italian Society of Surgical Oncology Colorectal Cancer Network Collaborative Group. Colorectal Dis 2022; 24:264-276. [PMID: 34816571 PMCID: PMC9300066 DOI: 10.1111/codi.15997] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 11/07/2021] [Accepted: 11/13/2021] [Indexed: 12/18/2022]
Abstract
AIM Anastomotic leakage after restorative surgery for rectal cancer shows high morbidity and related mortality. Identification of risk factors could change operative planning, with indications for stoma construction. This retrospective multicentre study aims to assess the anastomotic leak rate, identify the independent risk factors and develop a clinical prediction model to calculate the probability of leakage. METHODS The study used data from 24 Italian referral centres of the Colorectal Cancer Network of the Italian Society of Surgical Oncology. Patients were classified into two groups, AL (anastomotic leak) or NoAL (no anastomotic leak). The effect of patient-, disease-, treatment- and postoperative outcome-related factors on anastomotic leak after univariable and multivariable analysis was measured. RESULTS A total of 5398 patients were included, 552 in group AL and 4846 in group NoAL. The overall incidence of leaks was 10.2%, with a mean time interval of 6.8 days. The 30-day leak-related mortality was 2.6%. Sex, body mass index, tumour location, type of approach, number of cartridges employed, weight loss, clinical T stage and combined multiorgan resection were identified as independent risk factors. The stoma did not reduce the leak rate but significantly decreased leak severity and reoperation rate. A nomogram with a risk score (RALAR score) was developed to predict anastomotic leak risk at the end of resection. CONCLUSIONS While a defunctioning stoma did not affect the leak risk, it significantly reduced its severity. Surgeons should recognize independent risk factors for leaks at the end of rectal resection and could calculate a risk score to select high-risk patients eligible for protective stoma construction.
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Affiliation(s)
- Maurizio Degiuli
- Division of Surgical Oncology and Digestive SurgeryDepartment of OncologySan Luigi University HospitalUniversity of TurinTurinItaly
| | - Ugo Elmore
- Division of Gastrointestinal SurgerySan Raffaele HospitalMilanItaly
| | - Raffaele De Luca
- Department of Surgical OncologyIRCCS Istituto Tumori ‘G. Paolo II’BariItaly
| | - Paola De Nardi
- Division of Gastrointestinal SurgerySan Raffaele HospitalMilanItaly
| | | | - Alberto Biondi
- Fondazione Policlinico Gemelli—IRCCSAREA di Chirurgia AddominaleRomeItaly
| | - Roberto Persiani
- Fondazione Policlinico Gemelli—IRCCSAREA di Chirurgia AddominaleRomeItaly
| | - Leonardo Solaini
- General and Oncologic SurgeryMorgagni‐Pierantoni HospitalAusl RomagnaForlìItaly
| | - Gianluca Rizzo
- Fondazione Policlinico Universitario A. Gemelli—IRCCSChirurgia Generale Presidio ColumbusRomeItaly
| | - Domenico Soriero
- Surgical Oncology SurgeryIRCCS Policlinico San MartinoGenoaItaly
| | | | - Marco Milone
- Department of Clinical Medicine and SurgeryDepartment of Gastroenterology, Endocrinology and Endoscopic SurgeryUniversity of Naples ‘Federico II’NaplesItaly
| | - Giulia Turri
- Division of General and Hepatobiliary SurgeryDepartment of Surgical SciencesDentistry, Gynaecology and PaediatricsUniversity of VeronaVeronaItaly
| | - Daniela Rega
- Colorectal Surgical OncologyAbdominal Oncology DepartmentFondazione Giovanni Pascale IRCCSNaplesItaly
| | - Paolo Delrio
- Colorectal Surgical OncologyAbdominal Oncology DepartmentFondazione Giovanni Pascale IRCCSNaplesItaly
| | - Corrado Pedrazzani
- Division of General and Hepatobiliary SurgeryDepartment of Surgical SciencesDentistry, Gynaecology and PaediatricsUniversity of VeronaVeronaItaly
| | - Giovanni D. De Palma
- Department of Clinical Medicine and SurgeryDepartment of Gastroenterology, Endocrinology and Endoscopic SurgeryUniversity of Naples ‘Federico II’NaplesItaly
| | - Felice Borghi
- Department of SurgeryS. Croce e Carle HospitalCuneoItaly
| | - Stefano Scabini
- Surgical Oncology SurgeryIRCCS Policlinico San MartinoGenoaItaly
| | - Claudio Coco
- Fondazione Policlinico Universitario A. Gemelli—IRCCSChirurgia Generale Presidio ColumbusUniversità Cattolica del Sacro CuoreRomeItaly
| | - Davide Cavaliere
- General and Oncologic SurgeryMorgagni‐Pierantoni HospitalAusl RomagnaForlìItaly
| | - Michele Simone
- Department of Surgical OncologyIRCCS Istituto Tumori ‘G. Paolo II’BariItaly
| | - Riccardo Rosati
- Division of Gastrointestinal SurgerySan Raffaele HospitalVita Salute UniversityMilanItaly
| | - Rossella Reddavid
- Division of Surgical Oncology and Digestive SurgeryDepartment of OncologySan Luigi University HospitalUniversity of TurinTurinItaly
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9
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Wang Q, Li J, Liu S, Fang C, Chen W. Efficacy and safety of over-the-scope clips for colorectal leaks and fistulas: a pooled analysis. MINIM INVASIV THER 2021; 31:825-834. [PMID: 34871538 DOI: 10.1080/13645706.2021.2010218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The development of laparoscopic technologies and continuous improvements in intracavitary anastomosis technology have significantly reduced the incidence of anastomotic leak (AL) following colorectal surgery. However, AL incidence can significantly increase the duration of patient hospitalization, patient medical expenses, and incidence of mortality. The recently developed over-the-scope clip (OTSC) system has been of increasing clinical interest owing to its ease of use, low complication rates, and high rates of technical and clinical success. The PubMed/Medline, EMBASE, and Cochrane PubMed Library were systematically searched for all studies of OTSC system-mediated closure of ALs and fistulas published from January 2010 to January 2021. Two reviewers independently identified relevant studies based on appropriate inclusion and exclusion criteria. A total of nine studies were included in the present analysis, incorporating 114 patients of whom 107 were treated with an OTSC system. The technical success rate for these patients was 84% (95%CI, 73.5-94.5%; I2 53%), and the clinical success rate was 74.3% (95%CI, 64.4-84.1%; I2 28%) as calculated via a pooled proportion analysis. Complications occurred in two patients. The endoscopic OTSC system is a safe and effective means of treating ALs and fistulas after colorectal surgery.
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Affiliation(s)
- Qianyu Wang
- The Second Clinical Medical College of Shanxi Medical University, Taiyuan, China
| | - Jie Li
- The Second Clinical Medical College of Shanxi Medical University, Taiyuan, China
| | - Shuang Liu
- The Second Clinical Medical College of Shanxi Medical University, Taiyuan, China
| | - Changzhong Fang
- The Second Clinical Medical College of Shanxi Medical University, Taiyuan, China
| | - Wenliang Chen
- Department of General Surgery, The 2nd Affiliated Hospital of Shanxi Medical University, Taiyuan, China
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10
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Bhama AR, Maykel JA. Diagnosis and Management of Chronic Anastomotic Leak. Clin Colon Rectal Surg 2021; 34:406-411. [PMID: 34853562 DOI: 10.1055/s-0041-1732322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Chronic anastomotic leaks present a daunting challenge to colorectal surgeons. Unfortunately, anastomotic leaks are common, and a significant number of leaks are diagnosed in a delayed fashion. The clinical presentation of these chronic leaks can be silent or have low grade, indolent symptoms. Operative options can be quite formidable and highly complex. Leaks are typically diagnosed by radiographic and endoscopic imaging during the preoperative assessment prior to defunctioning stoma reversal. The operative strategy depends on the location of the anastomosis and the specific features of the anastomotic dehiscence. Low colorectal anastomosis (i.e. following low anterior resection) may require a transanal approach, transabdominal approach, or a combination of the two. While restoration of bowel continuity is encouraged, it is not infrequent for a permanent ostomy to be required to maximize patient quality of life.
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Affiliation(s)
- Anuradha R Bhama
- Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland, OH
| | - Justin A Maykel
- Division of Colorectal Surgery, Department of Surgery, University of Massachusetts, Wooster, Massachusetts
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11
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Chiari D, LA Raja C, Mangiavillano B, Veronesi P, Platto M, Zuliani W. Multimodal treatment of colorectal postsurgical leaks: long-term results of the over-thescope clip (OTSC) application. Minerva Surg 2021; 77:313-317. [PMID: 34338454 DOI: 10.23736/s2724-5691.21.08781-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Post-surgical anastomotic colorectal leaks often require a surgical second look with a definite morbidity and the risk of delaying adjuvant treatment. The aim of this study is to analyse the long-term results of the endoscopic closure of colorectal leak following low anterior resection (LAR) using the over-the-scope (Ovesco™) clip. METHODS Patients who were submitted to endoscopic closure of a colorectal leak of maximum 2 cm with an Ovesco™ clip following LAR from 2016 to 2018 were enrolled in this retrospective single-center study (Humanitas Mater Domini Clinical Institute, Italy). The follow-up was obtained through radiologic and clinic assessments. RESULTS In the study period 48 patients were submitted to LAR. Six patients were enrolled in the study. The median diameter of the leak was 7 mm. 14/6t or 12/6t OTSC® clip was applied. Three patients were managed exclusively endoscopically, 2 of them had a protective ileostomy; 3 patients underwent urgent laparotomy with ostomy and then underwent endoscopic procedure. Complete healing was reached in all patients in a median of 23 days. Adjuvant chemotherapy was indicated and performed in 4 patients after a median of 64 days from the surgery. Among the 5 carriers of an ostomy, 4 patients underwent recanalization. The median follow-up was 21.5 months. During the follow-up no leak reoccurrence or complications were reported. CONCLUSIONS In the multimodal management of anastomotic leaks following LAR , Ovesco™ clipping system appears a safe and effective technique in the closure of small leaks (<2 cm), allowing an early recanalization of the bowel and not delaying adjuvant chemotherapy when indicated.
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Affiliation(s)
- Damiano Chiari
- Department of General Surgery, Istituto Clinico Humanitas Mater Domini, Castellanza, Varese, Italy -
| | - Carlotta LA Raja
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy.,Humanitas Clinical and Research Center - IRCCS, Rozzano, Milan, Italy
| | - Benedetto Mangiavillano
- Department of General Surgery, Istituto Clinico Humanitas Mater Domini, Castellanza, Varese, Italy
| | - Paolo Veronesi
- Department of General Surgery, Istituto Clinico Humanitas Mater Domini, Castellanza, Varese, Italy
| | - Marco Platto
- Department of General Surgery, Istituto Clinico Humanitas Mater Domini, Castellanza, Varese, Italy
| | - Walter Zuliani
- Department of General Surgery, Istituto Clinico Humanitas Mater Domini, Castellanza, Varese, Italy
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12
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Mari G, Achilli P, Crippa J, Cordaro G, Berardi V, Di Fratta E, Maggioni D. Laparoscopic treatment of diffuse peritonitis for ileocolic anastomotic leak following totally laparoscopic right hemicolectomy. SURGICAL PRACTICE 2020. [DOI: 10.1111/1744-1633.12461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Giulio Mari
- Department of General Surgery Desio Hospital Desio (MB) Italy
| | - Pietro Achilli
- University of Milan, General Surgery Residency Program Milan Italy
| | - Jacopo Crippa
- University of Milan, General Surgery Residency Program Milan Italy
| | - Giuseppe Cordaro
- University of Milan, General Surgery Residency Program Milan Italy
| | - Valter Berardi
- Department of General Surgery Desio Hospital Desio (MB) Italy
| | | | - Dario Maggioni
- Department of General Surgery Desio Hospital Desio (MB) Italy
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13
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Thiruvengadam NR, Hamerski C, Nett A, Bhat Y, Shah J, Bernabe J, Kane S, Binmoeller K, Watson RR. Effectiveness of combination endoscopic therapy for colonic anastomotic leaks. Endoscopy 2020; 52:886-890. [PMID: 32521549 DOI: 10.1055/a-1176-0967] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Colonic anastomotic leaks are associated with significant morbidity and mortality. Whereas small case series suggest that fully covered self-expandable metal stents (FCSEMS) are effective, no larger studies have examined the impact of combination endoscopic therapy on colonic anastomotic leaks. METHODS Our retrospective cohort study reviewed 51 patients undergoing endoscopic therapy for colonic anastomotic leaks between 2011 and 2018. Patients receiving combination therapy involving FCSEMS plus local closure (n = 24) were compared with patients receiving FCSEMS alone (n = 18) or endoscopic suturing alone (n = 9). The primary outcomes were technical and clinical success (resolution of leak, removal of percutaneous drains, avoidance of surgical reoperation, and reversal of temporary diversion). RESULTS Clinical success was achieved in 55 % of patients. Clinical success was achieved in 18/24 patients (75 %) with combination therapy compared with 6/18 patients receiving FCSEMS alone (33 %, adjusted risk ratio [RR] 2.16, 95 % confidence interval [CI] 1.10 - 4.24; P = 0.02) and 4 /9 patients undergoing endoscopic suturing alone (44 %, RR 1.91, 95 %CI 0.84 - 4.31; P = 0.10). Stent migration occurred in 40 % of patients. CONCLUSIONS This large series demonstrates that combination therapy was associated with a higher rate of clinical success, and future prospective studies are warranted.
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Affiliation(s)
- Nikhil R Thiruvengadam
- Division of Gastroenterology, UCSF Medical Center, San Francisco, California, United States
| | - Christopher Hamerski
- Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California, United States
| | - Andrew Nett
- Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California, United States
| | - Yasser Bhat
- Division of Gastroenterology, Palo Alto Medical Foundation, Palo Alto, California, United States
| | - Janak Shah
- Division of Gastroenterology, Ochsner Medical Center, Louisiana, United States
| | - Jona Bernabe
- Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California, United States
| | - Steven Kane
- Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California, United States
| | - Kenneth Binmoeller
- Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California, United States
| | - Rabindra R Watson
- Interventional Endoscopy Services, California Pacific Medical Center, San Francisco, California, United States
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14
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Bartell N, Bittner K, Kaul V, Kothari TH, Kothari S. Clinical efficacy of the over-the-scope clip device: A systematic review. World J Gastroenterol 2020; 26:3495-3516. [PMID: 32655272 PMCID: PMC7327783 DOI: 10.3748/wjg.v26.i24.3495] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 05/19/2020] [Accepted: 05/29/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The over-the-scope clip (OTSC) system has been increasingly utilized as a non-surgical option to endoscopically manage refractory gastrointestinal (GI) hemorrhage, perforations/luminal defects and fistulas. Limited data exist evaluating the efficacy and safety of OTSC.
AIM To determine the clinical success and adverse event (AE) rates of OTSC across all GI indications.
METHODS A PubMed search was conducted for eligible articles describing the application of the OTSC system for any indication in the GI tract. Any article or case series reporting data for less than 5 total patients was excluded. The primary outcome was the rate of clinical success. Secondary outcomes included: Technical success rate, OTSC-related AE rate and requirement for surgical intervention despite-OTSC placement. Pooled rates (per-indication and overall) were calculated as the number of patients with the event of interest divided by the total number of patients.
RESULTS A total of 85 articles met our inclusion criteria (n = 3025 patients). OTSC was successfully deployed in 94.4% of patients (n = 2856/3025). The overall rate of clinical success (all indications) was 78.4% (n = 2371/3025). Per-indication clinical success rates were as follows: (1) 86.0% (1120/1303) for GI hemorrhage; (2) 85.3% (399/468) for perforation; (3) 55.8% (347/622) for fistulae; (4) 72.6% (284/391) for anastomotic leaks; (5) 92.8% (205/221) for defect closure following endoscopic resection (e.g., following endoscopic mucosal resection or endoscopic submucosal dissection); and (6) 80.0% (16/20) for stent fixation. AE’s related to the deployment of OTSC were only reported in 64 of 85 studies (n = 1942 patients), with an overall AE rate of 2.1% (n = 40/1942). Salvage surgical intervention was required in 4.7% of patients (n = 143/3025).
CONCLUSION This systematic review demonstrates that the OTSC system is a safe and effective endoscopic therapy to manage GI hemorrhage, perforations, anastomotic leaks, defects created by endoscopic resections and for stent fixation. Clinical success in fistula management appears limited. Further studies, including randomized controlled trials comparing OTSC with conventional and/or surgical therapies, are needed to determine which indication(s) are the most effective for its use.
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Affiliation(s)
- Nicholas Bartell
- Division of Gastroenterology and Hepatology, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - Krystle Bittner
- Division of Gastroenterology and Hepatology, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - Vivek Kaul
- Division of Gastroenterology and Hepatology, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - Truptesh H Kothari
- Division of Gastroenterology and Hepatology, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - Shivangi Kothari
- Division of Gastroenterology and Hepatology, University of Rochester Medical Center, Rochester, NY 14642, United States
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15
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Chorti A, Stavrou G, Stelmach V, Tsaousi G, Michalopoulos A, Papavramidis TS, Kotzampassi K. Endoscopic repair of anastomotic leakage after low anterior resection for rectal cancer: A systematic review. Asian J Endosc Surg 2020; 13:141-146. [PMID: 31297989 DOI: 10.1111/ases.12733] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 06/09/2019] [Accepted: 06/12/2019] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Anastomotic leakage (AL) after low anterior resection for rectal cancer is a severe complication. Except for re-operation, several endoscopic options have been proposed for the minimal invasive treatment of AL, including the endoluminal vacuum devices, tissue sealants and Over-The-Scope-Clip (OTSC) technique. The aim of the present review is to evaluate the effect of alternative treatment options for AL repair, by means of endoscopy. METHOD A bibliographic search was performed in the international literature. Ten case reports and series were finally included, reporting 75 cases of endoscopic repair of AL. A descriptive statistical analysis and a systematic review were performed. RESULTS The patients' mean age was 65.84 ± 9.92 years (95% CI: 61.70-68.76), the male-to-female ratio being 1.5:1. The mean diameter of the cavity was 5.17 ± 3.32 cm (95% CI: 4.03-6.31). The mean time until the diagnosis was 44.15 ± 105.91 days (95% CI: 13.39-74.90). Vacuum-assisted closure therapy was the most common technique (52%), followed by fibrin glue (25.3%) and OTSC (22.7%). As supplementary therapy, OTSC was applied in 8.3%, vacuum-assisted closure in 25%, endoclips in 4.2%, while fibrin glue was the most frequently used (62.5%). CONCLUSION Endoscopic management of AL after low anterior resection is considered as an alternative to surgical treatment with promising results.
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Affiliation(s)
- Angeliki Chorti
- Department of Surgery, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - George Stavrou
- Department of Surgery, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Veronica Stelmach
- Department of Surgery, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Georgia Tsaousi
- Department of Surgery, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Antonios Michalopoulos
- Department of Surgery, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Theodosios S Papavramidis
- Department of Surgery, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Katerina Kotzampassi
- Department of Surgery, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
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16
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Ghoz H, Brahmbhatt B, Odah T, Foulks C, Woodward TA. Endoscopic identification and clipping of an anastomotic leak after colorectal surgery by use of methylene blue dye and over-the-scope clipping system. VideoGIE 2019; 4:476-477. [PMID: 31709335 PMCID: PMC6831911 DOI: 10.1016/j.vgie.2019.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Hassan Ghoz
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Bhaumik Brahmbhatt
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Tarek Odah
- Division of General Internal Medicine, MetroWest Medical Center, Framingham, Massachusetts, USA
| | - Carla Foulks
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Timothy A Woodward
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
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17
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Morrell DJ, Winder JS, Johri A, Docimo S, Juza RM, Witte SR, Alli VV, Pauli EM. Over-the-scope clip management of non-acute, full-thickness gastrointestinal defects. Surg Endosc 2019; 34:2690-2702. [PMID: 31350610 DOI: 10.1007/s00464-019-07030-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 07/19/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Endoscopic management of full-thickness gastrointestinal tract defects (FTGID) has become an attractive management strategy, as it avoids the morbidity of surgery. We have previously described the short-term outcomes of over-the-scope clip management of 22 patients with non-acute FTGID. This study updates our prior findings with a larger sample size and longer follow-up period. METHODS A retrospective analysis of prospectively collected data was conducted. All patients undergoing over-the-scope clip management of FTGID between 2013 and 2019 were identified. Acute perforations immediately managed and FTGID requiring endoscopic suturing were excluded. Patient demographics, endoscopic adjunct therapies, number of endoscopic interventions, and need for operative management were evaluated. Success was strictly defined as complete FTGID closure. RESULTS We identified 92 patients with 117 FTGID (65 fistulae and 52 leaks); 27.2% had more than one FTGID managed simultaneously. The OTSC device (Ovesco Endoscopy, Tubingen, Germany) was utilized in all cases. Additional closure attempts were required in 22.2% of defects. With a median follow-up period of 5.5 months, overall defect closure success rate was 66.1% (55.0% fistulae vs. 79.6% leaks, p = 0.007). There were four mortalities from causes unrelated to the FTGID. Only 14.9% of patients with FTGID underwent operative management. There were no complications related to endoscopic intervention and no patients required urgent surgical intervention. CONCLUSIONS Over-the-scope clip management of FTGID represents a safe alternative to potentially morbid operative intervention. When strictly defining success as complete closure of all FTGID, endoscopy was successful in 64.4% of patients with only a small minority of patients ultimately requiring surgery.
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Affiliation(s)
- David J Morrell
- Department of Surgery, Division of Minimally Invasive and Bariatric Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Joshua S Winder
- Department of Surgery, Division of Minimally Invasive and Bariatric Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Ansh Johri
- Penn State College of Medicine, Hershey, PA, USA
| | - Salvatore Docimo
- Department of Surgery, Division of Minimally Invasive and Bariatric Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Ryan M Juza
- Department of Surgery, Division of Minimally Invasive and Bariatric Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Samantha R Witte
- Department of Surgery, Division of Minimally Invasive and Bariatric Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Vamsi V Alli
- Department of Surgery, Division of Minimally Invasive and Bariatric Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Eric M Pauli
- Department of Surgery, Division of Minimally Invasive and Bariatric Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA. .,Department of Surgery, Division of Minimally Invasive and Bariatric Surgery, College of Medicine, The Pennsylvania State University, 500 University Drive, H149, Hershey, PA, 17033-0850, USA.
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18
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Weiland T, Rohrer S, Schmidt A, Wedi E, Bauerfeind P, Caca K, Khashab MA, Hochberger J, Baur F, Gottwald T, Schurr MO. Efficacy of the OTSC System in the treatment of GI bleeding and wall defects: a PMCF meta-analysis. MINIM INVASIV THER 2019; 29:121-139. [PMID: 30957599 DOI: 10.1080/13645706.2019.1590418] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Since its market launch in 2007, the endoscopic OTSC clipping system has been the object of intensive clinical research. These data were systematically collected for post-market clinical follow-up (PMCF). The aim of the study was the systematic review of the efficacy and safety of the OTSC System. The PMCF database was systematically searched for clinical data on OTSC therapy of GI hemorrhage (H), acute leaks/perforations (AL) and chronic leaks/fistulae (CL). Major outcomes were successful clip application and durable hemostasis/closure of defects. Comprehensive pooled success proportions were established by meta-analytical methods. Four-hundred-fifty-seven publications were reviewed. Fifty-eight articles comprising 1868 patients fulfilled criteria to be included in the analysis. These consisted of retrospective analyses, prospective observational trials, one randomized-controlled trial (STING) and one quasi-controlled study (FLETRock). The pooled proportion analysis revealed high overall proportions of technical success: H - mean 93.0% [95%CI 90.2-95.4], AL-mean 89.7% [95%CI 85.9-92.9] and CL-mean 83.8% [95%CI 76.9-89.7]. Pooled durable clinical success proportions were: H-mean 87.5% [95%CI 80.5-93.2], AL-mean 81.4% [95%CI 77.0-85.3] and CL-mean 63.0% [95%CI 53.0-72.3]. By pooling all clinical data gained, we conclude that OTSC application in GI hemorrhage and closure of GI lesions is safe and effective in real clinical use.
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Affiliation(s)
| | | | - Arthur Schmidt
- Faculty of Medicine, Department of Medicine II, Medical Center, University of Freiburg, Freiburg, Germany.,Department of Gastroenterology and Oncology, Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Edris Wedi
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Centre Goettingen, Goettingen, Germany
| | - Peter Bauerfeind
- Department of Gastroenterology and Hepatology, Triemli Hospital, Zurich, Switzerland
| | - Karel Caca
- Department of Gastroenterology and Oncology, Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Mouen A Khashab
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, MA, USA
| | - Juergen Hochberger
- Department of Gastroenterology, Vivantes Klinikum in Friedrichshain, Berlin, Germany
| | | | - Thomas Gottwald
- Ovesco Endoscopy AG, Tuebingen, Germany.,Medical Faculty, Eberhard Karls University, Tuebingen, Germany
| | - Marc O Schurr
- Ovesco Endoscopy AG, Tuebingen, Germany.,Steinbeis University, Berlin, IHCI-Institute, Tuebingen, Germany
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19
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Clifford RE, Fowler H, Govindarajah N, Vimalachandran D, Sutton PA. Early anastomotic complications in colorectal surgery: a systematic review of techniques for endoscopic salvage. Surg Endosc 2019; 33:1049-1065. [PMID: 30675662 PMCID: PMC6430759 DOI: 10.1007/s00464-019-06670-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 01/17/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Anastomotic complications following colorectal surgery are associated with significant morbidity and mortality. For patients in whom systemic sepsis is absent or well controlled, minimal access techniques, such as endoscopic therapies, are being increasingly employed to reduce the morbidity of surgical re-intervention. In this review, we aim to assess the utility of endoscopic management in the acute setting of colorectal anastomotic complications, focusing on anastomotic leak. METHOD A literature search was performed for published full text articles using the PubMed, Cochrane and Scopus databases using the search criteria string "colorectal anastomotic ("leak" OR "bleed"), "endoscopy", endoscopic management". Additional papers were detected by scanning the references of relevant papers. Data were extracted from each study by two authors onto a dedicated pro-forma. Given the nature of the data extracted, no meta-analysis was performed. RESULTS A total of 89 papers were identified, 16 of which were included in this review; an additional 14 papers were obtained from reference searches. In patients who are not physiologically compromised, there are promising data regarding the salvage rate of stents, over-the-scope endoscopic clips, vacuum therapy and fibrin glue in the early management of colorectal anastomotic leak. There is no consensus regarding the optimal approach, and data to assist the physician in patient selection are lacking. Whilst data on salvage (i.e. healing and avoidance of surgery) are well understood, no data on functional outcomes are reported. CONCLUSION Endoscopic therapy in the management of stable patients with colorectal anastomotic leaks appears safe and in selected patients is associated with high rates of technical success. Challenges remain in selecting the most appropriate strategy, patient selection, and understanding the functional and long-term sequelae of this approach. Further evidence from large prospective cohort studies are needed to further evaluate the role of these novel strategies.
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Affiliation(s)
- R E Clifford
- Institute of Cancer Medicine, University of Liverpool, Liverpool, L69 3GE, UK.
| | - H Fowler
- Institute of Cancer Medicine, University of Liverpool, Liverpool, L69 3GE, UK
| | - N Govindarajah
- Institute of Cancer Medicine, University of Liverpool, Liverpool, L69 3GE, UK
| | - D Vimalachandran
- The Countess of Chester Hospital NHS Foundation Trust, Chester, UK
| | - P A Sutton
- The Countess of Chester Hospital NHS Foundation Trust, Chester, UK
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20
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Roy J, Sims K, Rider P, Grimm L, Hunter J, Richards W. Endoscopic technique for closure of enterocutaneous fistulas. Surg Endosc 2019; 33:3464-3468. [DOI: 10.1007/s00464-018-06646-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 12/21/2018] [Indexed: 12/20/2022]
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21
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Shelygin YA, Nagudov MA, Ponomarenko AA, Alekseev MV, Rybakov EG, Tarasov MA, Achkasov SI. [Meta-analysis of management of colorectal anastomotic leakage]. Khirurgiia (Mosk) 2018:30-41. [PMID: 30199049 DOI: 10.17116/hirurgia201808230] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
AIM To identify the most effective management of colorectal anastomosis failure via analysis of available literature sources. RESULTS Systematic review included 20 original trials. Effectiveness of redo interventions for colorectal anastomosis failure including open, laparoscopic, minimally invasive techniques (transanal drainage, endoscopic vacuum therapy, endoscopic drainage) was described. Anastomotic failure rate was 6.5%. Medication was effective in 57% (95% CI 34-77%) of cases. Redo open surgery was applied in 43% (95% CI 23-66%) of patients. Postoperative mortality was 21-27%. Redo laparoscopic procedure was performed in 61% (95% CI 50-70%) of cases for anastomotic failure after previous laparoscopy, incidence of conversion was 12% (95% CI 4-28%). Transanal drainage was effective in 85% (95% CI 61-94%) of cases, endoscopic vacuum therapy - in 82% (95% CI 74-87%), healing of anastomosis without need for colostomy was achieved in 16% (95% CI 9-26%) of cases. Endoscopic clipping for colorectal anastomotic defect was effective in 73.3-77% of cases. CONCLUSION Redo surgery for anastomotic failure is associated with advanced mortality and need for permanent colostomy. Laparoscopic approach reduces incidence of complications after redo surgery and followed by better functional outcomes. Minimally invasive procedures are advisable for colorectal anastomosis failure without need for redo surgery. However, effectiveness of these methods is controversial due to few reports and no comparative trials.
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Affiliation(s)
- Yu A Shelygin
- Ryzhikh State Medical Coloproctology Center of Healthcare Ministry of Russia, Moscow, Russian Federation; Russian Medical Academy of Continuing Professional Education of Healthcare Ministry of Russia, Moscow, Russian Federation
| | - M A Nagudov
- Ryzhikh State Medical Coloproctology Center of Healthcare Ministry of Russia, Moscow, Russian Federation
| | - A A Ponomarenko
- Ryzhikh State Medical Coloproctology Center of Healthcare Ministry of Russia, Moscow, Russian Federation
| | - M V Alekseev
- Ryzhikh State Medical Coloproctology Center of Healthcare Ministry of Russia, Moscow, Russian Federation; Russian Medical Academy of Continuing Professional Education of Healthcare Ministry of Russia, Moscow, Russian Federation
| | - E G Rybakov
- Ryzhikh State Medical Coloproctology Center of Healthcare Ministry of Russia, Moscow, Russian Federation
| | - M A Tarasov
- Ryzhikh State Medical Coloproctology Center of Healthcare Ministry of Russia, Moscow, Russian Federation
| | - S I Achkasov
- Ryzhikh State Medical Coloproctology Center of Healthcare Ministry of Russia, Moscow, Russian Federation
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Abstract
The development of new endoscopic techniques, such as gastrointestinal (GI) stenting, full-thickness suturing, clip application, and use of tissue adhesives, has had a significant impact on management of GI fistulae. These techniques have shown promising results, but further study is needed to optimize the efficacy of long-term closure. The advancement of endoscopic techniques, including the use of the lumen apposing metal stent (LAMS), has allowed for the deliberate creation of fistula tracts to apply endoscopic therapy that previously could not be achieved. This article examines the rapidly evolving area of endoscopic fistula closure and its relationship to LAMS.
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Affiliation(s)
- Jaehoon Cho
- Department of Internal Medicine, Los Angeles County and University of Southern California Medical Center, 2020 Zonal Avenue, IRD 620, Los Angeles, CA 90033, USA
| | - Ara B Sahakian
- Division of Gastrointestinal and Liver Diseases, University of Southern California Keck School of Medicine, 1510 San Pablo Street, Los Angeles, CA 90033, USA.
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23
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Lee HL, Cho JY, Cho JH, Park JJ, Kim CG, Kim SH, Han JH. Efficacy of the Over-the-Scope Clip System for Treatment of Gastrointestinal Fistulas, Leaks, and Perforations: A Korean Multi-Center Study. Clin Endosc 2017; 51:61-65. [PMID: 28847073 PMCID: PMC5806921 DOI: 10.5946/ce.2017.027] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 06/15/2017] [Accepted: 06/15/2017] [Indexed: 02/06/2023] Open
Abstract
Background/Aims Currently, a new over-the-scope clip (OTSC) system has been introduced. This system has been used for gastrointestinal perforations and fistulas in other countries. The aim of our study is to examine the therapeutic success rate of endoscopic treatment using the OTSC system in Korea. Methods This was a multicenter prospective study. A total of seven endoscopists at seven centers performed this procedure. Results A total of 19 patients were included, with gastrointestinal leakages from anastomosis sites, fistulas, or esophageal perforations due to Boerhaave’s syndrome. Among these, there were three gastrojejunostomy sites, three esophagojejunostomy sites, four esophagogastrostomy sites, one esophagocolonostomy site, one jejuno-jejunal site, two endoscopic full thickness resection site closures, one Boerhaave’s syndrome, two esophago-bronchial fistulas, one gastrocolonic fistula, and one colonopseudocyst fistula. The size of the leakage ranged from 5 to 30 mm. The median procedure time was 16 min. All cases were technically successful. Complete closure of the leak was achieved in 14 of 19 patients using OTSC alone. Conclusions The OTSC system is a safe and effective method for the management of gastrointestinal leakage, especially in cases of anastomotic leakage after surgery.
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Affiliation(s)
- Hang Lak Lee
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - Joo Young Cho
- Digestive Disease Center, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Jun-Hyung Cho
- Digestive Disease Center, Soonchunhyang University Hospital, Seoul, Korea
| | - Jong Jae Park
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Chan Gyoo Kim
- Center for Gastric Cancer, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Seong Hwan Kim
- Department of Gastroenterology, Eulji University School of Medicine, Eulji Hospital, Seoul, Korea
| | - Joung-Ho Han
- Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
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24
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Wedi E, Fischer A, Hochberger J, Jung C, Orkut S, Richter-Schrag HJ. Multicenter evaluation of first-line endoscopic treatment with the OTSC in acute non-variceal upper gastrointestinal bleeding and comparison with the Rockall cohort: the FLETRock study. Surg Endosc 2017; 32:307-314. [PMID: 28656336 DOI: 10.1007/s00464-017-5678-7] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Accepted: 06/19/2017] [Indexed: 12/15/2022]
Abstract
INTRODUCTION The over-the-scope clip (OTSC) overcomes limitations of standard clips and achieves a more efficient and reliable hemostasis in non-variceal upper gastrointestinal bleeding (NVUGIB). The study aims to evaluate mortality, rebleeding, and mortality after rebleeding of patients in whom the OTSC was used as the first-line endoscopic treatment (FLET) of NVUGIB. PATIENTS AND METHODS In total, 118 patients (FLET cohort) with a median age of 73.5 years (range 29-93 years; mean (±SD) 71.39 ± 12.39 years) were included. The distribution of patients with respect to risk category revealed a median Rockall score of 7 (range 3-10). For hypothesis testing, the FLET cohort was categorized into three risk groups taking into account the Rockall score: low risk [Rockall risk category (RRC ≤3)], moderate risk (RRC 4-7), and high risk (RRC ≥8). Event rates (mortality, rebleeding, and mortality after rebleeding) observed per risk group were compared to predicted event rates (Rockall cohort) using Fisher's Exact Test. RESULTS Primary successful hemostasis (PSH) was achieved in 92.4% either by FLET alone or in combination with an additional hemostasis technique in 1.7% (SCS = secondary clinical success). In 7.5% of the FLET cohort PSH could not be achieved. Compared to RRC prediction, mortality after rebleeding was significantly reduced from 27.9 to 10.9% in the high-risk group (RRC ≥8) treated with FLET (p < 0.011). Furthermore, the occurrence of rebleeding or continued bleeding was significantly lower in the moderate risk group (RRC 4-7) with 4.9% as well as in the high-risk group (RRC ≥8) with 21.4% compared to the Rockall cohort 24.0 and 53.2%, respectively (p < 0.001). CONCLUSIONS This study shows that OTSC is superior to standard care and FLET reduces significantly rebleeding and rebleeding-associated mortality in NVUGIB. For this reason, OTSC could be the treatment of choice as the first-line treatment as an alternative to standard hemostasis techniques in high-risk patients.
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Affiliation(s)
- E Wedi
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Centre Goettingen, Georg-August-University, Robert-Koch-Straße 40, 37075, Goettingen, Germany.
| | - A Fischer
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, 79106, Freiburg, Germany
| | - J Hochberger
- Departement of Gastroenterology, Vivantes Klinikum in Friedrichshain, Teaching Hospital of Charité Humboldt University, 10249, Berlin, Germany
| | - C Jung
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Centre Goettingen, Georg-August-University, Robert-Koch-Straße 40, 37075, Goettingen, Germany
| | - S Orkut
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Centre Goettingen, Georg-August-University, Robert-Koch-Straße 40, 37075, Goettingen, Germany
| | - H J Richter-Schrag
- Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, 79106, Freiburg, Germany
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Han S, Chung H, Park JC, Shin SK, Lee SK, Lee YC. Endoscopic Management of Gastrointestinal Leaks and Perforation with Polyglycolic Acid Sheets. Clin Endosc 2017; 50:293-296. [PMID: 28268263 PMCID: PMC5475508 DOI: 10.5946/ce.2016.121] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 11/15/2016] [Accepted: 11/15/2016] [Indexed: 12/17/2022] Open
Abstract
Gastrointestinal (GI) leakage, fistulae, and perforations can be serious and life threatening. There has been a paradigm shift in the management approach of these conditions, from surgical to conservative, including endoscopic management. Here, we report two cases of endoscopic closure of a GI fistula and perforation using polyglycolic acid (PGA) sheets with fibrin glue. The first case is of an anastomotic leak detected after subtotal gastrectomy with gastroduodenostomy. After failed application of endoclips, a PGA sheet was applied, and the fistula was successfully closed. The second case was of a 15-mm large perforated gastric ulcer, which was also successfully closed with a PGA sheet. This is the first case report that PGA sheet was used for the treatment of overt perforation. The outcome of these cases suggest that endoscopic closure using PGA sheets can be considered as a useful alternative for the management of GI leakage, fistulae, and perforations.
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Affiliation(s)
- Sojung Han
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hyunsoo Chung
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Jun Chul Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung Kwan Shin
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Kil Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yong Chan Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea.,Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Dango S, Antonakis F, Schrader D, Radzikhovskiy A, Ghadimi MB, Hesterberg R. Long-term efficacy and safety of a nitinol closure clip system for anal fistula treatment. MINIM INVASIV THER 2017; 26:227-231. [PMID: 28151035 DOI: 10.1080/13645706.2017.1282521] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Treatment failure of anal fistula results in high re-occurrence rate. MATERIAL AND METHODS Efficacy and safety of a nitinol closure clip system (bear-claw clip) were evaluated for anal fistulae treatment in a 36-month long-term follow-up study. RESULTS Twenty-two patients were included. No patient had been treated with a bear-claw clip system before. All patients were fully continent before treatment. Follow-up time was 36 months (range 19-48 months). We observed a re-occurrence rate of 41% (nine patients) with presence of an active fistula. Time to recurrence was on average 6.9 months (range 3-11 months). Thirteen patients (59%) showed a complete healing of the fistula. Placed clip was removed in all patients on average after almost 5.8 months (3-12 months), in three cases the clip was left in situ. We did not observe any incontinence; one patient reported recurrent burning after defecation once the clip system was removed. DISCUSSIONS Clip placement is a minimally invasive sphincter-preserving procedure with minimal complications and with an acceptable recurrence rate in the long term. However, bear-claw clip placement should probably be offered patients as a treatment option before more invasive procedures with higher perioperative morbidity are taken into consideration.
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Affiliation(s)
- Sebastian Dango
- a Clinic for General- and Visceral Surgery , Rotes Kreuz Krankenhaus Kassel , Kassel , Germany.,b Department of General, Visceral and Pediatric Surgery , University Medical Center Goettingen , Goettingen , Germany
| | - Fillimon Antonakis
- a Clinic for General- and Visceral Surgery , Rotes Kreuz Krankenhaus Kassel , Kassel , Germany
| | - Dirk Schrader
- a Clinic for General- and Visceral Surgery , Rotes Kreuz Krankenhaus Kassel , Kassel , Germany
| | - Arkadiy Radzikhovskiy
- a Clinic for General- and Visceral Surgery , Rotes Kreuz Krankenhaus Kassel , Kassel , Germany
| | - Michael B Ghadimi
- b Department of General, Visceral and Pediatric Surgery , University Medical Center Goettingen , Goettingen , Germany
| | - Rudolf Hesterberg
- a Clinic for General- and Visceral Surgery , Rotes Kreuz Krankenhaus Kassel , Kassel , Germany
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Kim H. Over-the-Scope Clip in the Management of Gastrointestinal Defect and Intractable Non-Variceal Bleeding. Clin Endosc 2017; 50:3-5. [PMID: 28147475 PMCID: PMC5299984 DOI: 10.5946/ce.2017.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 01/19/2017] [Accepted: 01/19/2017] [Indexed: 02/07/2023] Open
Affiliation(s)
- Hyungkil Kim
- Division of Gastroenterology, Department of Internal Medicine, Inha University College of Medicine, Incheon, Korea
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Sevim Y, Celik SU, Yavarifar H, Akyol C. Minimally invasive management of anastomotic leaks in colorectal surgery. World J Gastrointest Surg 2016; 8:621-626. [PMID: 27721925 PMCID: PMC5037335 DOI: 10.4240/wjgs.v8.i9.621] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 07/06/2016] [Accepted: 07/22/2016] [Indexed: 02/06/2023] Open
Abstract
Anastomotic leakage is an unfortunate complication of colorectal surgery. This distressing situation can cause severe morbidity and significantly affects the patient’s quality of life. Additional interventions may cause further morbidity and mortality. Parenteral nutrition and temporary diverting ostomy are the standard treatments of anastomotic leaks. However, technological developments in minimally invasive treatment modalities for anastomotic dehiscence have caused them to be used widely. These modalities include laparoscopic repair, endoscopic self-expandable metallic stents, endoscopic clips, over the scope clips, endoanal repair and endoanal sponges. The review aimed to provide an overview of the current knowledge on the minimally invasive management of anastomotic leaks.
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Wedi E, Gonzalez S, Menke D, Kruse E, Matthes K, Hochberger J. One hundred and one over-the-scope-clip applications for severe gastrointestinal bleeding, leaks and fistulas. World J Gastroenterol 2016; 22:1844-1853. [PMID: 26855543 PMCID: PMC4724615 DOI: 10.3748/wjg.v22.i5.1844] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Revised: 09/27/2015] [Accepted: 12/01/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the efficacy and clinical outcome of patients treated with an over-the-scope-clip (OTSC) system for severe gastrointestinal hemorrhage, perforations and fistulas.
METHODS: From 02-2009 to 10-2012, 84 patients were treated with 101 OTSC clips. 41 patients (48.8%) presented with severe upper-gastrointestinal (GI) bleeding, 3 (3.6%) patients with lower-GI bleeding, 7 patients (8.3%) underwent perforation closure, 18 patients (21.4%) had prevention of secondary perforation, 12 patients (14.3%) had control of secondary bleeding after endoscopic mucosal resection or endoscopic submucosal dissection (ESD) and 3 patients (3.6%) had an intervention on a chronic fistula.
RESULTS: In 78/84 patients (92.8%), primary treatment with the OTSC was technically successful. Clinical primary success was achieved in 75/84 patients (89.28%). The overall mortality in the study patients was 11/84 (13.1%) and was seen in patients with life threatning upper GI hemorrhage. There was no mortality in any other treatment group. In detail OTSC application lead to a clinical success in 35/41 (85.36%) patients with upper GI bleeding and in 3/3 patients with lower GI bleeding. Technical success of perforation closure was 100% while clinical success was seen in 4/7 cases (57.14%) due to attendant circumstances unrelated to the OTSC. Technical and clinic success was achieved in 18/18 (100%) patients for the prevention of bleeding or perforation after endoscopic mucosal resection and ESD and in 3/3 cases of fistula closure. Two application-related complications were seen (2%).
CONCLUSION: This largest single center experience published so far confirms the value of the OTSC for GI emergencies and complications. Further clinical experience will help to identify optimal indications for its targeted and prophylactic use.
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Blumetti J, Abcarian H. Management of low colorectal anastomotic leak: Preserving the anastomosis. World J Gastrointest Surg 2015; 7:378-383. [PMID: 26730283 PMCID: PMC4691718 DOI: 10.4240/wjgs.v7.i12.378] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 09/05/2015] [Accepted: 10/13/2015] [Indexed: 02/06/2023] Open
Abstract
Anastomotic leak continues to be a dreaded complication after colorectal surgery, especially in the low colorectal or coloanal anastomosis. However, there has been no consensus on the management of the low colorectal anastomotic leak. Currently operative procedures are reserved for patients with frank purulent or feculent peritonitis and unstable vital signs, and vary from simple fecal diversion with drainage to resection of the anastomosis and closure of the rectal stump with end colostomy (Hartmann’s procedure). However, if the patient is stable, and the leak is identified days or even weeks postoperatively, less aggressive therapeutic measures may result in healing of the leak and salvage of the anastomosis. Advances in diagnosis and treatment of pelvic collections with percutaneous treatments, and newer methods of endoscopic therapies for the acutely leaking anastomosis, such as use of the endosponge, stents or clips, have greatly reduced the need for surgical intervention in selected cases. Diverting ileostomy, if not already in place, may be considered to reduce fecal contamination. For subclinical leaks or those that persist after the initial surgery, endoluminal approaches such as injection of fibrin sealant, use of endoscopic clips, or transanal closure of the very low anastomosis may be utilized. These newer techniques have variable success rates and must be individualized to the patient, with the goal of treatment being restoration of gastrointestinal continuity and healing of the anastomosis. A review of the treatment of low colorectal anastomotic leaks is presented.
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Rendezvous EndoSeel Technique for Non-operative Closure of Anastomotic Leak After Ileoanal Pouch Operation. Dig Dis Sci 2015; 60:3545-8. [PMID: 25868632 DOI: 10.1007/s10620-015-3657-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Accepted: 04/01/2015] [Indexed: 12/25/2022]
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Willingham FF, Buscaglia JM. Endoscopic Management of Gastrointestinal Leaks and Fistulae. Clin Gastroenterol Hepatol 2015; 13:1714-21. [PMID: 25697628 DOI: 10.1016/j.cgh.2015.02.010] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2014] [Revised: 02/04/2015] [Accepted: 02/05/2015] [Indexed: 02/07/2023]
Abstract
Gastrointestinal leaks and fistulae can be serious acute complications or chronic morbid conditions resulting from inflammatory, malignant, or postsurgical states. Endoscopic closure of gastrointestinal leaks and fistulae represents major progress in the treatment of patients with these complex presentations. The main goal of endoscopic therapy is the interruption of the flow of luminal contents across a gastrointestinal defect. In consideration of the proper endoscopic approach to luminal closure, several basic principles must be considered. Undrained cavities and fluid collections must often first be drained percutaneously, and the percutaneous drain provides an important measure of safety for subsequent endoscopic luminal manipulations. The size and exact location of the leak/fistula, as well as the viability of the surrounding tissue, must be defined. Almost all complex leaks and fistulae must be approached in a multidisciplinary manner, collaborating with colleagues in nutrition, radiology, and surgery. Currently, gastrointestinal leaks and fistulae may be managed endoscopically by using 1 or more of the following modalities: stent placement, clip closure (including through-the-scope clips and over-the-scope devices), endoscopic suturing, and the injection of tissue sealants. In this article, we discuss these modalities and review the published outcomes data regarding each approach as well as practical considerations for successful closure of luminal defects.
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Affiliation(s)
- Field F Willingham
- Division of Digestive Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia.
| | - Jonathan M Buscaglia
- Division of Gastroenterology, Department of Medicine, Stony Brook University School of Medicine, Stony Brook, New York
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Predictors of Successful Endoscopic Closure of Gastrointestinal Defects: Experience from a Single Tertiary Care Center. J Gastrointest Surg 2015; 19:1691-8. [PMID: 26070889 DOI: 10.1007/s11605-015-2868-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2015] [Accepted: 05/28/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND/AIMS Endoscopic closure is technically feasible in the majority of gastrointestinal defects. The aim of this study is to evaluate the technical and clinical outcomes, and identify variables predicting successful outcomes in patients with attempted closure. METHODS This is a retrospective study of patients undergoing endoscopic closure of gastrointestinal defects between December 2007 and May 2013 at a single tertiary care center. Technical success (TS) was defined as successful closure of the defect at the time of endoscopy. Clinical improvement (CI) was defined as improvement in symptoms. Clinical resolution (CR) was defined as documented radiographic closure of defect or clinical resolution of symptoms. Acute defects were diagnosed within 6 weeks, while chronic defects were those that persisted for >6 weeks, prior to index therapeutic endoscopy. RESULTS Fifty patients underwent 77 endoscopies for leaks (n = 23), fistulas (n = 22), and perforations (n = 5). TS occurred in 46/50 (92%). Overall, 34/50 (68%) patients had CR. CR was significantly higher for acute defects as compared to chronic defects (89.7 vs. 38.1%, OR 14.1, CI 3.19-62.1, p < 0.001). Of 24 patients who required repeat attempts at endoscopic closure, 14 (58%) achieved CR. Acute defects (p = 0.04) and those with initial CI (p = 0.001) were statistically more likely to achieve CR after a repeat attempt. CONCLUSION TS and CR are achieved in majority of patients. Acute defects are more likely to achieve CR. In cases where a defect persists, a repeat attempt at endoscopic closure should be attempted.
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The over-the-scope clipping system for treatment of chronic coloenteric fistula: a case report. World J Surg Oncol 2015; 13:219. [PMID: 26183216 PMCID: PMC4514455 DOI: 10.1186/s12957-015-0628-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2015] [Accepted: 06/15/2015] [Indexed: 01/11/2023] Open
Abstract
Anastomotic leak in colorectal surgery is not very unusual. The over-the-scope clipping (OTSC) system (Ovesco), which was originally developed to treat intestinal perforation and was tested with animals, might be the choice for the patient. We presented the case of a 63-year-old man with chronic coloenteric fistula. Conservative treatment was unsuccessful. The orifice was then closed with two subsequent clips, and the patient recovered well. To our knowledge, this is the first successful case of coloenteric fistula treatment with Ovesco.
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35
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Complications during colonoscopy: prevention, diagnosis, and management. Tech Coloproctol 2015; 19:505-13. [PMID: 26162284 DOI: 10.1007/s10151-015-1344-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2015] [Accepted: 06/07/2015] [Indexed: 02/08/2023]
Abstract
Colonoscopy is largely performed in daily clinical practice for both diagnostic and therapeutic purposes. Although infrequent, different complications may occur during the examination, mostly related to the operative procedures. These complications range from asymptomatic and self-limiting to serious, requiring a prompt medical, endoscopic or surgical intervention. In this review, the complications that may occur during colonoscopy are discussed, with a particular focus on prevention, diagnosis, and therapeutic approaches.
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Oderda M, Bonet X, Campobasso D, Gaston R. Robotic rectovesical fistula repair: a successful approach. J Laparoendosc Adv Surg Tech A 2015; 24:567-70. [PMID: 25062340 DOI: 10.1089/lap.2014.0002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To describe our technique of robotic rectovesical fistula (RVF) repair through the report of a case unique for its pathogenesis. RVF is a rare but devastating complication of prostatic surgery and can nowadays be managed with a minimally invasive approach. PATIENT AND METHODS We describe in detail all the steps of our robotic RVF repair, performed on a 76-year-old man who developed RVF after radical prostatectomy. The RVF had been induced by tissue erosion due to Hem-o-lok(®) (Teleflex Medical, Research Triangle Park, NC) clips and had been unsuccessfully treated with an over-the-scope clip. RESULTS Our surgery was successful with an operative time of 70 minutes and an estimated blood loss of 150 mL. The postoperative course was uneventful, and the patient was discharged on postoperative Day 3. CONCLUSIONS Our technique of robotic RVF repair was safe and effective. Care must be taken when considering new, endoscopic devices for the cure of RVF. A prospective study with a long follow-up is advised to validate our results.
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Affiliation(s)
- Marco Oderda
- 1 Department of Urology, Clinique Saint Augustin , Bordeaux, France
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Arezzo A, Verra M, Passera R, Bullano A, Rapetti L, Morino M. Long-term efficacy of endoscopic vacuum therapy for the treatment of colorectal anastomotic leaks. Dig Liver Dis 2015; 47:342-5. [PMID: 25563812 DOI: 10.1016/j.dld.2014.12.003] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Revised: 10/29/2014] [Accepted: 12/03/2014] [Indexed: 12/11/2022]
Abstract
BACKGROUND Anastomotic leaks are a severe complication after colorectal surgery. We aimed to evaluate the long-term efficacy of endoscopic vacuum therapy for their treatment. METHODS Retrospective review of a series of post-surgical colorectal leaks treated with endoscopic vacuum therapy, with minimum follow-up of 1 year. Generalized peritonitis or haemodynamic instability was considered contraindication to endoscopic treatment. RESULTS Endoscopic vacuum therapy was applied in 14 patients with colorectal leak, in 2 cases complicated by recto-vaginal fistula. Overall success rate was 79%, favoured by early beginning of treatment (90%) and presence of a stoma (100%) and no preoperative radiotherapy (86%). Median duration of treatment was 12.5 sessions (range 4-40). Median time for complete healing was 40.5 days (range 8-114), for a median cost of treatment of 3125 Euros. No complication related to endoscopic vacuum therapy was observed. Further surgery was required in 3 cases. CONCLUSION Endoscopic vacuum therapy is a safe treatment for post-surgical leaks, with high success rates.
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Affiliation(s)
- Alberto Arezzo
- Department of Surgical Sciences, University of Torino, Italy.
| | - Mauro Verra
- Department of Surgical Sciences, University of Torino, Italy
| | - Roberto Passera
- Department of Surgical Sciences, University of Torino, Italy
| | - Alberto Bullano
- Department of Surgical Sciences, University of Torino, Italy
| | - Lisa Rapetti
- Department of Surgical Sciences, University of Torino, Italy
| | - Mario Morino
- Department of Surgical Sciences, University of Torino, Italy
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New devices and techniques for handling adverse events: claw, suture, or cover? Gastrointest Endosc Clin N Am 2015; 25:159-68. [PMID: 25442965 DOI: 10.1016/j.giec.2014.09.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Increasingly invasive therapeutic endoscopic procedures and laparoscopic surgeries have resulted in endoscopists being challenged more frequently with perforations, fistulas, and anastomotic leakages, for which nonsurgical closure is desired. Devices and techniques are available and in development for endoscopic closure of gastrointestinal wall defects. Currently available devices with excellent clinical success rates include the over-the-scope clip and an endoscopic suturing system. Another device, the cardiac septal defect occluder, has been adapted for use in the gastrointestinal tract. Extensive endoscopic knowledge, a highly trained endoscopy team, and the availability of devices and equipment are required to manage complications endoscopically.
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Dauser B, Herbst F. Diagnosis, management and outcome of early anastomotic leakage following colorectal anastomosis using a compression device: is it different? Colorectal Dis 2014; 16:O435-9. [PMID: 25132419 DOI: 10.1111/codi.12742] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2014] [Accepted: 05/20/2014] [Indexed: 01/20/2023]
Abstract
AIM Compression anastomosis has proved to be safe for rectal reconstruction with leak rates comparable to those observed using circular stapling devices. However, there are no data on whether the metallic compression ring alters the ease of diagnosis or the treatment in cases of leakage. In this study, we present our experience with early leakage following compression anastomosis. METHOD A prospective registry was used for data review. Patients with anastomotic leakage following compression anastomosis between November 2008 and September 2013 were included. RESULTS In all, 197 (92 female) patients were operated using a novel compression device. Early leakage was found in 10 (5.1%) patients after a median of 5 (3-14) days. The radiologist was able to detect leakage using CT in nine out of 10 cases unequivocally. Removal of the ring was necessary in eight of the 10 cases, and salvage of the anastomosis was feasible on six occasions. In all diverted cases with a low anastomosis, a transanal repair of the defect was feasible in three cases, including a single patient with complete separation of the anastomosis. CONCLUSION Artefacts on the CT scan caused by the compression ring did not hamper the diagnosis of anastomotic leakage. Removal of the ring in the early postoperative period is not associated with complete separation of the bowel ends. Salvage of anastomosis is feasible in most cases.
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Affiliation(s)
- B Dauser
- Department of Surgery, St John of God Hospital, Vienna, Austria
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Schurr MO, Baur FE, Krautwald M, Fehlker M, Wehrmann M, Gottwald T, Prosst RL. Endoscopic full-thickness resection and clip defect closure in the colon with the new FTRD system: experimental study. Surg Endosc 2014; 29:2434-41. [PMID: 25318369 DOI: 10.1007/s00464-014-3923-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 09/22/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND The benefit of endoscopic full-thickness resection is the improved diagnostic work-up with an integral wall specimen which allows a precise determination of the tumor or its precursor and its infiltration depth into the wall. MATERIALS AND METHODS A new endoscopic full-thickness resection device (FTRD), which is a combination of a modified over-the-scope-clip (OTSC) system with an electrocautery snare, has been tested in an experimental setting. In eleven pigs, divided into three groups, endoscopic full-thickness resection was performed in the colon at one or two sites, respectively. Seven days (n = 7) or 28 days (n = 4) after the intervention, the animals were euthanized following endoscopic examination of the resection and clip application sites. Furthermore, two different clips were tested during these animal trials in order to evaluate the most effective clip design. RESULTS The average diameter of the tissue resected with the FTRD was 3.1, 3.6, and 5.4 cm in the three groups. On follow-up endoscopy 7 days after the intervention, fibrin coating and stool residues were found at all clips, causing minor inflammatory reactions. However, the colon wall under the clip was non-inflamed. After 28 days, the serosa had primarily healed in all cases. There were also stool residues at all clips; however, no acute inflammatory reactions were seen anymore, due to complete healing. Histological assessment did not show any signs of dehiscence in the region of the scar, or ischemia in the clip area. In addition, no wound infections, such as abscess formation, were observed. CONCLUSIONS This study demonstrates the safety and efficacy of the clip-and-cut technique using the new FTRD system. With the device, a local full-thickness colon resection can be easily created, and the resulting wall defect is reliably sealed by the endoluminal application of a modified OTSC clip.
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Law R, Wong Kee Song LM, Irani S, Baron TH. Immediate technical and delayed clinical outcome of fistula closure using an over-the-scope clip device. Surg Endosc 2014; 29:1781-6. [PMID: 25277480 DOI: 10.1007/s00464-014-3860-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 08/21/2014] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND STUDY AIMS An over-the-scope clip (OTSC) device was designed for closure of acute perforations, fistulas, leaks, and non-variceal gastrointestinal bleeding. Previous data show a high rate of early fistula closure using the OTSC; however, data on long-term fistula closure are scant. We report our experience using an OTSC for closure of chronic gastrointestinal fistulas. PATIENTS AND METHODS Retrospective review of all patients, who underwent OTSC placement at Mayo Clinic Rochester and Virginia Mason Medical Center for closure of chronic fistulas from October 2011 to September 2012, was performed. Initial technical success was defined by lack of contrast extravasation immediately after OTSC placement. Delayed success was defined by resolution of the fistula without the need for additional therapies. Recurrent fistula was defined by the recurrence of symptoms and/or re-demonstration of fistula after initial success. RESULTS Forty-seven unique patients (24 men; mean age 57 ± 14 years) underwent 60 procedures using the OTSC for closure of gastrointestinal fistulas. Fistula locations were: small bowel (n = 18), stomach (n = 16), colo-rectum (n = 10), and esophagus (n = 3). Fistulas related to previous percutaneous endoscopic gastrostomy/jejunostomy (n = 10) or prior bariatric procedure (n = 10) were the most common etiologies. Initial technical success occurred in 42/47 (89%) index cases; however, 19/41 (46%) patients developed fistula recurrence at a median of 39 days (IQR 26-86 days). The retained OTSC was present adjacent to the fistula in 16/19 (84%) at repeat intervention. Patients were followed for a median length of 178 days (IQR 63-326 days), and only 25/47 (53%) patients demonstrated delayed clinical success using OTSC. CONCLUSIONS Initial technical fistula closure can be achieved using OTSCs. Recurrent fistulas at the same location occur in approximately 50% of cases despite frequent OTSC clip retention.
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Affiliation(s)
- Ryan Law
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA,
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Haito-Chavez Y, Law JK, Kratt T, Arezzo A, Verra M, Morino M, Sharaiha RZ, Poley JW, Kahaleh M, Thompson CC, Ryan MB, Choksi N, Elmunzer BJ, Gosain S, Goldberg EM, Modayil RJ, Stavropoulos SN, Schembre DB, DiMaio CJ, Chandrasekhara V, Hasan MK, Varadarajulu S, Hawes R, Gomez V, Woodward TA, Rubel-Cohen S, Fluxa F, Vleggaar FP, Akshintala VS, Raju GS, Khashab MA. International multicenter experience with an over-the-scope clipping device for endoscopic management of GI defects (with video). Gastrointest Endosc 2014; 80:610-622. [PMID: 24908191 DOI: 10.1016/j.gie.2014.03.049] [Citation(s) in RCA: 190] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Accepted: 03/27/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND The over-the-scope clip (OTSC) provides more durable and full-thickness closure as compared with standard clips. Only case reports and small case series have reported on outcomes of OTSC closure of GI defects. OBJECTIVE To describe a large, multicenter experience with OTSCs for the management of GI defects. Secondary goals were to determine success rate by type of defect and type of therapy and to determine predictors of treatment outcomes. DESIGN Multicenter, retrospective study. SETTING Multiple, international, academic centers. PATIENTS Consecutive patients who underwent attempted OTSC placement for GI defects, either as a primary or as a rescue therapy. INTERVENTIONS OTSC placement to attempt closure of GI defects. MAIN OUTCOME MEASUREMENTS Long-term success of the procedure. RESULTS A total of 188 patients (108 fistulae, 48 perforations, 32 leaks) were included. Long-term success was achieved in 60.2% of patients during a median follow-up of 146 days. Rate of successful closure of perforations (90%) and leaks (73.3%) was significantly higher than that of fistulae (42.9%) (P < .05). Long-term success was significantly higher when OTSCs were applied as primary therapy (primary 69.1% vs rescue 46.9%; P = .004). On multivariate analysis, patients who had OTSC placement for perforations and leaks had significantly higher long-term success compared with those who had fistulae (OR 51.4 and 8.36, respectively). LIMITATIONS Retrospective design and multiple operators with variable expertise with the OTSC device. CONCLUSION OTSC is safe and effective therapy for closure of GI defects. Clinical success is best achieved in patients undergoing closure of perforations or leaks when OTSC is used for primary or rescue therapy. Type of defect is the best predictor of successful long-term closure.
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Affiliation(s)
- Yamile Haito-Chavez
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Joanna K Law
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Thomas Kratt
- Department of General, Visceral and Transplant Surgery, University Hospital of Tübingen, Tübingen, Germany
| | - Alberto Arezzo
- Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Mauro Verra
- Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Mario Morino
- Department of Surgical Sciences, University of Torino, Torino, Italy
| | - Reem Z Sharaiha
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York, USA
| | - Jan-Werner Poley
- Department of Gastroenterology and Hepatology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Michel Kahaleh
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York, USA
| | | | - Michele B Ryan
- Division of Gastroenterology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Neel Choksi
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - B Joseph Elmunzer
- Division of Gastroenterology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Sonia Gosain
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Eric M Goldberg
- Division of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Rani J Modayil
- Division of Gastroenterology, Hepatology and Nutrition, Winthrop University Hospital, Mineola, New York, USA
| | - Stavros N Stavropoulos
- Division of Gastroenterology, Hepatology and Nutrition, Winthrop University Hospital, Mineola, New York, USA
| | - Drew B Schembre
- Swedish Gastroenterology, Swedish Medical Center, Seattle, Washington, USA
| | - Christopher J DiMaio
- Division of Gastroenterology, The Mount Sinai Medical Center, New York, New York, USA
| | - Vinay Chandrasekhara
- Gastroenterology Division, Department of Internal Medicine, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Muhammad K Hasan
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA
| | - Shyam Varadarajulu
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA
| | - Robert Hawes
- Center for Interventional Endoscopy, Florida Hospital, Orlando, Florida, USA
| | - Victoria Gomez
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Timothy A Woodward
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Sergio Rubel-Cohen
- Department of Gastroenterology, Clinica Las Condes, Universidad de Chile, Santiago, Chile
| | - Fernando Fluxa
- Department of Gastroenterology, Clinica Las Condes, Universidad de Chile, Santiago, Chile
| | - Frank P Vleggaar
- Department of Gastroenterology and Hepatology, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Gottumukkala S Raju
- Department of Gastroenterology, Hepatology, and Nutrition, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Mouen A Khashab
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland, USA
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Mennigen R, Senninger N, Laukoetter MG. Novel treatment options for perforations of the upper gastrointestinal tract: Endoscopic vacuum therapy and over-the-scope clips. World J Gastroenterol 2014; 20:7767-7776. [PMID: 24976714 PMCID: PMC4069305 DOI: 10.3748/wjg.v20.i24.7767] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 02/23/2014] [Accepted: 03/13/2014] [Indexed: 02/06/2023] Open
Abstract
Endoscopic management of leakages and perforations of the upper gastrointestinal tract has gained great importance as it avoids the morbidity and mortality of surgical intervention. In the past years, covered self-expanding metal stents were the mainstay of endoscopic therapy. However, two new techniques are now available that enlarge the possibilities of defect closure: endoscopic vacuum therapy (EVT), and over-the-scope clip (OTSC). EVT is performed by mounting a polyurethane sponge on a gastric tube and placing it into the leakage. Continuous suction is applied via the tube resulting in effective drainage of the cavity and the induction of wound healing, comparable to the application of vacuum therapy in cutaneous wounds. The system is changed every 3-5 d. The overall success rate of EVT in the literature ranges from 84% to 100%, with a mean of 90%; only few complications have been reported. OTSCs are loaded on a transparent cap which is mounted on the tip of a standard endoscope. By bringing the edges of the perforation into the cap, by suction or by dedicated devices, such as anchor or twin grasper, the OTSC can be placed to close the perforation. For acute endoscopy associated perforations, the mean success rate is 90% (range: 70%-100%). For other types of perforations (postoperative, other chronic leaks and fistulas) success rates are somewhat lower (68%, and 59%, respectively). Only few complications have been reported. Although first reports are promising, further studies are needed to define the exact role of EVT and OTSC in treatment algorithms of upper gastrointestinal perforations.
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Kobayashi H, Kikuchi A, Okazaki S, Ishiguro M, Ishikawa T, Iida S, Uetake H, Sugihara K. Over-the-scope-clipping system for anastomotic leak after colorectal surgery: Report of two cases. World J Gastroenterol 2014; 20:7984-7987. [PMID: 24976736 PMCID: PMC4069327 DOI: 10.3748/wjg.v20.i24.7984] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Revised: 02/14/2014] [Accepted: 03/10/2014] [Indexed: 02/06/2023] Open
Abstract
An anastomotic leak is one of the major complications following colorectal surgery. Standard treatments for anastomotic leak are total parenteral nutrition or temporary ileostomy. The over-the-scope-clipping (OTSC) system was originally developed to treat intestinal perforation or to close the tissue after natural orifice transluminal endoscopic surgery. Two cases of successful management of an anastomotic leak after colorectal surgery using the OTSC system are reported. One patient avoided a temporary ileostomy. In the other, hospitalization was shortened by the use of the OTSC system. The OTSC system can be a potential option in the management of anastomotic leaks after colorectal surgery.
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Landmann RG. Surgical management of anastomotic leak following colorectal surgery. SEMINARS IN COLON AND RECTAL SURGERY 2014. [DOI: 10.1053/j.scrs.2014.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Manta R, Magno L, Conigliaro R, Caruso A, Bertani H, Manno M, Zullo A, Frazzoni M, Bassotti G, Galloro G. Endoscopic repair of post-surgical gastrointestinal complications. Dig Liver Dis 2013; 45:879-85. [PMID: 23623147 DOI: 10.1016/j.dld.2013.03.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Revised: 01/28/2013] [Accepted: 03/09/2013] [Indexed: 12/11/2022]
Abstract
Complications following gastrointestinal surgery may require re-intervention, can lead to prolonged hospitalization, and significantly increase health costs. Some complications, such as anastomotic leakage, fistula, and stricture require a multidisciplinary approach. Therapeutic endoscopy may play a pivotal role in these conditions, allowing minimally invasive treatment. Different endoscopic approaches, including fibrin glue injection, endoclips, self-expanding stents, and endoscopic vacuum-assisted devices have been introduced for both anastomotic leakage and fistula treatment. Similarly endoscopic treatments, such as endoscopic dilation, incisional therapy, and self-expanding stents have been used for anastomotic strictures. All these techniques can be safely performed by skilled endoscopists, and may achieve a high technical success rate in both the upper and lower gastrointestinal tract. Here we will review the endoscopic management of post-surgical complications; these techniques should be considered as first-line approach in selected patients, allowing to avoid re-operation, reduce hospital stay, and decrease costs.
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Affiliation(s)
- Raffaele Manta
- Gastroenterology and Endoscopy Unit, New S. Agostino Hospital, Modena, Italy.
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Prosst RL, Ehni W, Joos AK. The OTSC® Proctology clip system for anal fistula closure: first prospective clinical data. MINIM INVASIV THER 2013; 22:255-9. [PMID: 23971828 DOI: 10.3109/13645706.2013.826675] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
INTRODUCTION Anorectal fistulas represent a troublesome condition for both patient and surgeon. The OTSC® Proctology clip system is a new device for transanal anorectal fistula closure. MATERIAL AND METHODS The OTSC® Proctology system was evaluated in a prospective clinical study undertaken in two surgical proctological centers. Ten patients (three women, seven men; median age 55 years, range 25-73 years) with nine transsphincteric and one suprasphincteric fistulas were enrolled into the study. RESULTS The median operation time was 30 minutes (range 20-45 minutes). There were no intraoperative technical or surgical complications. Postoperatively, no patient reported intolerable discomfort, immoderate pain or foreign body sensation in the anal region. At follow-up examination six months after surgery, nine out of ten patients had no clinical signs or symptoms of their previous fistula and were considered as healed (success rate 90%). In one patient persistency of the fistula was noted due to spontaneous early clip detachment on the third postoperative day. DISCUSSION These first data demonstrate the efficacy of the OTSC® Proctology system in the treatment of anal fistulas. Currently, more patients were enrolled into this prospective study to allow further evaluation of this new device and to assess its future role in relation to established surgical strategies for anorectal fistulas.
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Abstract
Endoscopy has an ever-increasing role in the treatment of complications in digestive surgery. Endoscopic treatment is essentially used for (i) fistula or intra-abdominal collection secondary to anastomotic dehiscence and (ii) anastomotic stricture, especially esophagogastric, but also sometimes after colorectal surgery. First intention treatment of fistula following esophagogastric surgery is the insertion of an extractable self-expandable metallic stent (partially or entirely covered); this is supported by a low level of scientific evidence, but clinical experience has been satisfactory. Other techniques for treatment of anastomotic leak have also been reported anecdotally (clip placement, sealing with glue). There are few data available in the literature on endoscopic management (stents essentially) of postoperative colonic fistula. Whatever the approach chosen to treat a postoperative digestive tract fistula, management is medico-surgical and cannot be limited to simple closure of the digestive tube wall defect. Drainage of any collections by endoscopic, radiologic or surgical approach, systemic treatment of infection and nutritional support are essential adjuvant treatment modalities. Treatment of postoperative esophageal or colonic strictures is essentially endoscopic and is based on initial dilatation (endoscopic with hydrostatic balloon or bougie), and placement of extractable metallic stents (partially or entirely covered) in case of refractory outcome.
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Affiliation(s)
- X Dray
- Université Paris Diderot, Paris 7, AP-HP, Service d'Hépatogastroentérologie, Hôpital Lariboisière, 2, rue Ambroise-Paré, 75010 Paris, France.
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Arezzo A, Bullano A, Fischer H, Morino M. The way to remove an over-the-scope-clip (with video). Gastrointest Endosc 2013; 77:974-5. [PMID: 23684096 DOI: 10.1016/j.gie.2013.01.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Accepted: 01/24/2013] [Indexed: 12/11/2022]
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Mennigen R, Colombo-Benkmann M, Senninger N, Laukoetter M. Endoscopic closure of postoperative gastrointestinal leakages and fistulas with the Over-the-Scope Clip (OTSC). J Gastrointest Surg 2013; 17:1058-65. [PMID: 23400507 DOI: 10.1007/s11605-013-2156-y] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2012] [Accepted: 01/25/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND In contrast to conventional Through-the-Scope Clips, the novel Over-the-Scope Clip (OTSC(®)) allows endoscopic full thickness closure of gastrointestinal leakages. The purpose of this study was to evaluate the efficacy and safety of the OTSC for the management of postoperative gastrointestinal leakages and fistulas. METHODS We retrospectively reviewed a series of 14 consecutive patients with postoperative gastrointestinal leakages and fistulas who were treated by OTSC application. RESULTS Nine OTSCs were used for upper GI tract leakages; five were used for colorectal leakages. Seventy-nine percent (11/14) of leakages were chronic (treated by OTSC later than postoperative day 14). In nine patients, other therapies preceded OTSC application. Median follow-up time was 5.5 months (range, 0.25-17). Primary technical success was achieved in all (14/14) patients. No adverse events related to the use of the OTSC device were noted. Three early recurrences were observed (two colonic fistulas, one esophageal anastomotic leakage), leading to a long-term success rate of 79 % (11/14). Leakage closure finally was achieved in these three patients by surgery or endoscopic vacuum therapy. CONCLUSIONS The OTSC system is an effective and safe method for the management of postoperative leakages and fistulas of the gastrointestinal tract. Its exact place in treatment algorithms of postoperative leakages will have to be determined.
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Affiliation(s)
- Rudolf Mennigen
- Department of General and Visceral Surgery, University Hospital Muenster, Albert-Schweitzer-Campus 1, 48149, Muenster, Germany.
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