Performance of the OTSC System in the endoscopic closure of iatrogenic gastrointestinal perforations: a systematic review

Assessment and Techniques for Endoscopic Closure

Endoscopic closure is an essential technique to perform safe advanced endoscopy. Without appropriate closure of a defect, patients can experience spillage of fecal contents into the peritoneal cavity resulting in abdominal sepsis. The essential components to performing endoscopic closure are assessing the defect appropriately and choosing the correct closure technique. Assessing the defect involves five separate elements: timing, size, depth, shape, blood flow, and location in the colon or rectum. Understanding how each of these elements contributes toward a successful closure allows an endoscopist to choose the proper technique for closure. There have been many types of closure techniques described in the literature but the most common are through the scope clips, over the scope clips, and endoscopic suturing. There are advantages and disadvantages of each of these closure techniques. In this manuscript, we will discuss these common techniques as well as some additional techniques and the situations where they can be employed.

Clinical outcomes of the over-the-scope clip closure after duodenal endoscopic submucosal dissection: A multicenter retrospective study

BACKGROUND AND AIM

Prophylactic closure with the over-the-scope clip (OTSC) after endoscopic submucosal dissection (ESD) of superficial non-ampullary duodenal epithelial tumors (SNADETs) has been reported to reduce postoperative adverse events (AEs). However, there are few evidences regarding AEs-associated factors and long-term outcomes of OTSCs.

METHODS

From January 2011 to December 2020, 139 consecutive patients with SNADETs who underwent ESD followed by OTSC closure in five institutions were extracted in this retrospective study. The primary endpoint was the rate of postoperative AEs after prophylactic OTSC closure. The secondary endpoints were the complete closure rate, residual rate, and long-term AEs associated with residual OTSCs.

RESULTS

The rate of complete closure of the mucosal defect was 97.3% (142) in 146 SNADETs, which were completely resected by ESD. Postoperative AEs, including delayed bleeding, delayed perforation, and localized peritonitis, occurred in 6.2%, 3.4%, and 2.1% of patients, respectively; however, all of the cases improved without surgical treatment. In the multivariate logistic regression analysis, the use of two or more OTSCs was a significant independent risk factor for postoperative AEs (odds ratio, 2.94; 95% confidence interval, 1.02-8.46; P = 0.046). The residual OTSC rate was 46.4% at 1 year postoperatively, and long-term AEs included duodenal erosions and ulcers associated with residual OTSCs.

CONCLUSIONS

Prophylactic closure with OTSCs after duodenal ESD can provide acceptable short-and long-term outcomes for preventing postoperative AEs. However, multiple OTSCs were the independent risk factors of postoperative AEs due to the gaps between and near the OTSCs.

Endoscopic ultrasound-based application system for predicting endoscopic resection-related outcomes and diagnosing subepithelial lesions: Multicenter prospective study

OBJECTIVES

Subepithelial lesions (SELs) are associated with various endoscopic resection (ER) outcomes and diagnostic challenges. We aimed to establish a tool for predicting ER-related outcomes and diagnosing SELs and to investigate the predictive value of endoscopic ultrasound (EUS).

METHODS

Phase 1 (system development) was performed in a retrospective cohort (n = 837) who underwent EUS before ER for SELs at eight hospitals. Prediction models for five key outcomes were developed using logistic regression. Models with satisfactory internal validation performance were included in a mobile application system, SEL endoscopic resection predictor (SELERP). In Phase 2, the models were externally validated in a prospective cohort of 200 patients.

RESULTS

An SELERP was developed using EUS characteristics, which included 10 models for five key outcomes: post-ER ulcer management, short procedure time, long hospital stay, high medication costs, and diagnosis of SELs. In Phase 1, 10 models were derived and validated (C-statistics, 0.67-0.99; calibration-in-the-large, -0.14-0.10; calibration slopes, 0.92-1.08). In Phase 2, the derived risk prediction models showed convincing discrimination (C-statistics, 0.64-0.73) and calibration (calibration-in-the-large, -0.02-0.05; calibration slopes, 1.01-1.09) in the prospective cohort. The sensitivities and specificities of the five diagnostic models were 68.3-95.7% and 64.1-83.3%, respectively.

CONCLUSION

We developed and prospectively validated an application system for the prediction of ER outcomes and diagnosis of SELs, which could aid clinical decision-making and facilitate patient-physician consultation. EUS features significantly contributed to the prediction.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, http://www.chictr.org.cn (ChiCTR2000040118).

The value of single-channel endoscopic traction and kiss suture technique in closing wounds caused by endoscopic resection of gastrointestinal muscularis propria tumors

BACKGROUND

To investigate the value of single forceps endoscopic traction stapling suture technique (SFETSST) in closing wounds caused by endoscopic resection of gastrointestinal muscularis propria tumor (GMPT).

METHODS

Consecutive patients who underwent submucosal tumor excavation (ESE) and endoscopic full-thickness resection (EFR) for GMPT in the Second Affiliated Hospital of Xiamen Medical College from January 2015 to January 2022 were retrospectively collected. They were divided into the SFETSST group and the standard group (patients who receive single forceps traction-free endoscopic suture technique). The healing effects were compared between the two groups.

RESULTS

Seventy-seven patients were included in our study with 50 patients included in SFETSST group. The baseline characteristics had no significant difference between the two groups. The technical success rate of wound suture in SFETSST cluster was significantly upper than that within standard cluster (100% vs. 88.89%, P = 0.04). The wound suture time in SFETSST cluster was significantly lower than that within standard cluster (33.19 ± 10.64 min, P < 0.001). Moreover, the incidence rates of intra-operative and postoperative complications in SFETSST cluster were lower than standard cluster (0 vs. 7.41%, P = 0.051 and 0 vs. 11.11%, P = 0.016). Interestingly, the SFETSST cluster had lower cost of consumables (2485.40 ± 591.78 vs. 4098.52 ± 1903.06 Yuan, P = 0.01) and shorter hospital stay (4.96 ± 0.90 vs. 7.19 ± 2.45, P < 0.001) than standard cluster.

CONCLUSION

Our study showed that to fully closure the full-thickness defects of digestive tract, SFETSST was effective, safe, and economical, which was worth popularizing.

Recent advances and current challenges in endoscopic resection with the full-thickness resection device

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.

Endoscopic full‑thickness resection with clip‑ and snare‑assisted traction for gastric submucosal tumours in the fundus: A single‑centre case series

Exposed endoscopic full-thickness resection (Eo-EFTR) has been recognized as a feasible therapy for gastrointestinal submucosal tumours (SMTs) originating deep in the muscularis propria layer; however, Eo-EFTR is difficult to perform in a retroflexed fashion in the gastric fundus. As a supportive technique, clip- and snare-assisted traction may help expose the surgical field and shorten the operation time in endoscopic resection of difficult regions. However, the application of clip- and snare-assisted traction in Eo-EFTR of SMTs in the gastric fundus is limited. Between April 2018 and December 2021, Eo-EFTR with clip- and snare-assisted traction was performed in 20 patients with SMTs in the gastric fundus at The First Affiliated Hospital of Soochow University. The relevant clinical data were collected retrospectively for all of the patients and analysed. All 20 patients underwent Eo-EFTR successfully without conversion to open surgery or severe adverse events. The en bloc resection rate and R0 resection rate were both 100%. Two patients had abdominal pain and fever after the operation, and five patients had fever, which recovered with medical therapy. No complications, such as delayed bleeding or delayed perforation, were observed. The postoperative pathology indicated that 19 cases were gastrointestinal stromal tumours and one case was leiomyoma. During the follow-up, no residual tumour, local recurrence or distant metastasis was detected by endoscopy or abdominal computed tomography. In conclusion, Eo-EFTR with clip- and snare-assisted traction appears to be a relatively safe and effective treatment for gastric SMTs in the fundus. However, prospective studies on a larger sample size are required to verify the effect of the clip- and snare-assisted traction in Eo-EFTR.

Characteristics and endoscopic treatment of interventional and non-interventional iatrogenic colorectal perforations in centers with high endoscopic expertise: a retrospective multicenter study

BACKGROUND

Iatrogenic colorectal perforation is a rare event with a relevant mortality and the need for surgical therapy in around ¾ of cases.

METHODS

In this retrospective multicentric cohort study iatrogenic colorectal perforations from 2004 to 2021 were analyzed. Primary outcome parameters were incidence and clinical success of 1st line endoscopic treatment. Comparative analysis of interventional and non-interventional perforations was performed and predictors for clinical success of endoscopic therapy were identified.

RESULTS

From 103,570 colonoscopies 213 (0.2%) iatrogenic perforations were identified. 68.4% were interventional (80 during polypectomy/EMR, 54 during ESD and 11 for other reasons) and 31.6% non-interventional perforations (39 by the tip, 19 by the shaft, 7 by inversion, two by biopsy and one by distension). Incidence of 1st line endoscopic therapy was 61.0% and clinical success 81.5%. Other non-surgical therapies were conducted in 8.9% with clinical success in 94.7% of cases. In interventional perforations both incidence and clinical success of 1st line endoscopic therapy were significantly higher compared to non-interventional perforations [71.7% vs. 38.2% (p < 0.01) resp. 86.5% vs. 61.5% (p < 0.01)]. Mortality was 2.3% and significantly lower in the group of interventional perforations (0.7% vs. 5.9%, p = 0.037). Multivariable analysis revealed perforation size < 5 mm as only independent predictor for clinical success of 1st line endoscopic treatment [OR 14.85 (1.57-140.69), p = 0.019].

CONCLUSIONS

Endoscopic therapy is treatment of choice in the majority of iatrogenic colorectal perforations. In case of interventional perforations it is highly effective but only a minority of non-interventional perforations are good candidates for endoscopic treatment.

Feasibility and efficacy of endoscopic purse-string suture-assisted closure for mucosal defects induced by endoscopic manipulations

BACKGROUND

Large or transmural defects induced by gastrointestinal endoscopic manipulations are difficult to close, although complete closure is recommended for better recovery. Endoscopic purse-string assisted suturing (EPSS) has been used in clinical practice and has proven to be an effective and safe technique for the closure of large mucosal defects. However, details regarding the efficacy of endoscopic pre-purse-string suture (P-EPSS) are unknown, especially that it offers several advantages over conventional EPSS (C-EPSS).

AIM

To elucidate the outcomes of EPSS-assisted closure in different clinical situations, and evaluate the efficacy of P-EPSS.

METHODS

This retrospective observational study included a total of 180 patients who underwent closure assisted by P-EPSS (n = 63) or C-EPSS (n = 117) between July 2014 and June 2020. The P-EPSS and C-EPSS groups were compared and the intergroup differences in aspects such as the lesion size, location, and mor-phology, incidence of complete closure, intraoperative perforation, and delayed adverse events were evaluated. Data on the features and clinical course of cases with adverse events were collected for further analysis.

RESULTS

Patients with lesion size larger than 3 cm, lesions located at the fundus of stomach, or submucosal tumors originating from the deep mucosa were more likely to undergo P-EPSS-assisted closure. The P-EPSS group showed a sign-ificantly higher proportion of intraoperative perforation (56% vs 17%) and a much shorter procedure time (9.06 ± 6.14 min vs 14.84 ± 7.25 min). Among adverse events, the incidence of delayed perforation (5% vs 4%; P = 0.82) and delayed bleeding (3% vs 4%; P = 0.96) did not differ significantly between the groups. Multivariate analysis revealed that lesions with incomplete closure [odds ratio (OR) = 21.33; 95% confidence interval (CI): 5.45-83.45; P < 0.01] or size greater than 3 cm (OR = 3.14; 95%CI: 1.08-9.18; P = 0.039) showed a statistical tendency to result in an increase in delayed adverse events.

CONCLUSION

The present study revealed that EPSS could achieve secure complete closure of mucosal defect. P-EPSS could shorten the procedure and yield complete closure of mucosal defects. Rather than closure-type selection, incomplete closure or lesion size larger than 3 cm were associated with worse outcomes.

Manejo de perforaciones, fugas y fístulas del tracto gastrointestinal con clip sobre el endoscopio. Experiencia de un centro oncológico Latinoamericano

Introducción. Las fístulas derivadas de enfermedades neoplásicas del tracto digestivo, así como las fugas posteriores a procedimientos quirúrgicos, no son infrecuentes y ocasionan una morbilidad importante cuando se manejan de forma quirúrgica. También durante los procedimientos endoscópicos se pueden presentar perforaciones y, si se logra un manejo no operatorio, se alcanza una adecuada recuperación. El objetivo de este estudio fue describir las características clínicas y los resultados de los pacientes con perforaciones, fístulas y fugas del tracto gastrointestinal, manejadas endoscópicamente con clip sobre el endoscopio. Métodos. Estudio descriptivo, retrospectivo, de pacientes con perforación, fuga o fístula postoperatoria, llevados a endoscopía digestiva con colocación de clip sobre el endoscopio, en el Instituto Nacional de Cancerología en Bogotá, D.C., Colombia, entre enero de 2016 y abril de 2020. Resultados. Se incluyeron 21 pacientes, 52,4 % de ellos mujeres. La mediana de edad fue de 66 años y del diámetro del defecto fue de 9 mm. En el 95 % se logró éxito técnico. Hubo éxito clínico temprano en el 85,7 % de los casos. El 76,1 % de los pacientes permanecieron sin síntomas a los 3 meses de seguimiento. Conclusiones. El manejo de perforaciones, fugas y fístulas con clip sobre el endoscopio parece ser factible y seguro. En la mayoría de estos pacientes se logró la liberación del clip y la identificación endoscópica del cierre inmediatamente después del procedimiento; sin embargo, en el caso de las fístulas, no se alcanzó el éxito clínico tardío en todos los casos.

Gastric defect closure after endoscopic full-thickness resection: the closing while dissecting technique

BACKGROUND

Complete closure of gastric wall defects is critical following endoscopic full-thickness resection (EFTR). The aim of this study was to evaluate the efficacy, safety, and clinical outcome of a new endoscopic method: closing while dissecting.

METHODS

Twenty-seven patients who underwent EFTR were retrospectively analyzed between January 2020 and March 2021. Gastric defects resulting from EFTR were closed using the "interrupted-close during dissection" technique with endoclips. Tumor characteristics, en bloc resection rates, and postoperative adverse events were evaluated.

RESULTS

All submucosal tumors were successfully resected and complete resection was histologically confirmed. The mean maximal tumor diameter was 1.3 cm (ranging from 0.8 to 3.0 cm). The majority of these tumors were gastrointestinal stromal tumors (n = 20), Leiomyoma (n = 3), schwannomas (n = 2), others included fibroma (n = 1) and neurogenic tumor (n = 1). There were no cases of hemorrhage, peritonitis, or delayed perforation. Four patients complained of slight abdominal pain, but no hyperpyrexia or serious elevated white blood cell count was detected in the first 24 h after treatment. All wounds were healed on follow-up endoscopy 3 months after the procedure. The mean follow-up duration was 8.5 months (ranging from 3 to 17) and no tumor recurrences were observed.

CONCLUSIONS

The feasibility and safety of this interrupted-close during dissection approach allows for clinical applications in EFTR of gastric submucosal tumors.

Minimally invasive endoscopic repair of rectovaginal fistula

BACKGROUND

Surgical techniques for repair of rectovaginal fistula (RVF) have been continually developed, but the ideal procedure remains unclear. Endoscopic repair is a novel and minimally invasive technique for RVF repair with increasing reporting.

AIM

To review the current applications and preliminary outcomes of this technique for RVF repair, aiming to give surgeons an alternative in clinical practice.

METHODS

Available articles were searched according to the search strategy. And the sample size, fistula etiology, fistula type, endoscopic repair approaches, operative time and hospital stay, follow-up period, complication and life quality assessment were selected for recording and further analysis.

RESULTS

A total of 11 articles were eventually identified, involving 71 patients with RVFs who had undergone endoscopic repair. The principal causes of RVFs were surgery (n = 51, 71.8%), followed by obstetrics (n = 7, 9.8%), inflammatory bowel disease (n = 5, 7.0%), congenital (n = 3, 4.2%), trauma (n = 2, 2.8%), radiation (n = 1, 1.4%), and in two patients, the cause was unclear. Most fistulas were in a mid or low position. Several endoscopic repair methods were included, namely transanal endoscopic microsurgery, endoscopic clipping, and endoscopic stenting. Most patients underwent > 1-year follow-up, and the success rate was 40%-93%, and all cases reported successful closure. Few complications were mentioned, while postoperative quality of life assessment was only mentioned in one study.

CONCLUSION

In conclusion, endoscopic repair of RVF is novel, minimally invasive and promising with acceptable preliminary effectiveness. Given its unique advantages, endoscopic repair can be an alternative technique for surgeons.

Over-the-scope-clips versus standard treatment in high-risk patients with acute non-variceal upper gastrointestinal bleeding: a randomised controlled trial (STING-2)

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.

Over-the-Scope Clip Applications as First-Line Therapy in the Treatment of Upper Non-variceal Gastrointestinal Bleeding, Perforations, and Fistulas

Background

The over-the-scope clip (OTSC) is an innovative device and has been successfully used in endoscopic treatment, however, there is a lack of clinical data from China. The aim of this study is to investigate the OTSC applications in the treatment of upper non-variceal gastrointestinal bleeding (UNVGIB), perforations, and fistulas in China.

Methods

In total, 80 patients were treated with one OTSC respectively as first-line therapy in our endoscopy center between January 2016 and November 2020. Among them, 41 patients had UNVGIB, 34 patients had perforations, and five patients had fistulas. The technical and clinical success rates were used to assess the efficacy of OTSC on the above diseases. In addition, we compared the hemostatic efficacy of OTSC with the standard endoscopic therapy in ulcer bleeding and Dieulafoy's lesion by propensity score matching analysis.

Results

In general, the OTSCs were applied successfully in all patients and achieved 100% (80/80) technical success. The clinical success of all patients was 91.3% (73/80). Among 41 patients with UNVGIB, the clinical success was 85.4% (35/41); 6 patients presented with recurrence. For patients of Dieulafoy's lesion and under antithrombotic therapy, we found that OTSC treatment had both efficient and reliable hemostasis effects. In addition, according to the characteristics of ulcers, site of bleeding lesion, and Blatchford score, all patients received similar and reliable clinical success rates. After propensity score matching, we found that OTSC treatment had low rebleeding rates when compared with standard endoscopic therapy in both Dieulafoy's lesion (15.0 vs 30.0%) and ulcer bleeding (17.6 vs 29.4%). Among 34 patients with perforations, the clinical success was 100% (34/34). Among five patients with fistulas, only one patient failed in maintaining the OTSC before esophageal fistula healing, and the clip achieved an overall clinical success of 80% (4/5).

Conclusion

The OTSC represents a safe and effective endoscopic therapy for UNVGIB, perforations, and fistulas as first-line treatment, especially for Dieulafoy's lesion or patients under antithrombotic therapy for UNVGIB, etc. However, OTSC application in these specific lesions or patients lacks adequate evidence as first-line treatment. Therefore, further larger sample and multi-center clinical trials are required to improve its indications in clinical treatment.

Efficacy and safety of over-the-scope clips (OTSC®) for closure of gastrointestinal fistulas less than 2 cm

BACKGROUND AND AIM

Gastrointestinal (GI) fistula is a complication of surgery associated with potential morbidity and mortality. The aim of this study was to evaluate the efficacy and safety of over-the-scope clips (OTSC®) for closing GI fistulas.

METHODS

Patients with GI fistula who underwent endoscopic closure using OTSC® were enrolled. The clinical date, duration, location and diameter of the fistula, technical success of the OTSC®, complications, follow-up periods and clinical success were recorded.

RESULTS

A total of 98 patients with GI fistula underwent OTSC® closure. Their median age was 50 years (range 16-88 years), and the median duration of the fistula was 185.5 days (range 12-3129 days). The mean diameter of fistula was 4.64 ± 1.16 mm. Technical success was achieved in 100% of the patients, and clinical success was achieved in 55.10% (54/98) of the patients after a median follow-up of 168.5 days (range 36-424 days). Based on the location of the fistula, the clinical success rate of treating a fistula in the esophagus and small intestine was 100%, followed by the rectum (70%, 7/10), anastomotic stoma (61.90%, 13/21), duodenum (53.33%, 8/15), colon (47.06%, 8/17), stomach (43.47%, 10/23) and appendix stump (33.33%, 2/6). The duration of the fistula (HR 3.609, 95% CI 1.387-9.387, P = 0.009) was a risk factor for clinical success by multivariate analysis.

CONCLUSION

OTSC® is a safe and efficient treatment for GI fistula and is a potential alternative to the surgical approach. Before OTSC® placement, the duration of the fistula should be assessed since it is related to the successful closures with OTSC®.

Efficacy and safety of over-the-scope clips for colorectal leaks and fistulas: a pooled analysis

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.

Management of Acute Anastomotic Leaks

Management of the acute anastomotic leak is complex and patient-specific. Clinically stable patients often benefit from a nonoperative approach utilizing antibiotics with or without percutaneous drainage. Clinically unstable patients or nonresponders to conservative management require operative intervention. Surgical management is dictated by the degree of contamination and inflammation but includes drainage with proximal diversion, anastomotic resection with end-stoma creation, or reanastomosis with proximal diversion. Newer therapies, including colorectal stenting, vacuum-assisted rectal drainage, and endoscopic clipping, have also been described.

Closure techniques in exposed endoscopic full-thickness resection: Overview and future perspectives in the endoscopic suturing era

Exposed endoscopic full-thickness resection (EFTR) without laparoscopic assistance is a minimally invasive natural orifice transluminal endoscopic surgery technique that is emerging as a promising effective and safe alternative to surgery for the treatment of muscularis propria-originating gastric submucosal tumors. To date, various techniques have been used for the closure of the transmural post-EFTR defect, mainly consisting in clip- and endoloop-assisted closure methods. However, the recent advent of dedicated tools capable of providing full-thickness defect suture could further improve the efficacy and safety of the exposed EFTR procedure. The aim of our review was to evaluate the efficacy and safety of the different closure methods adopted in gastric-exposed EFTR without laparoscopic assistance, also considering the recent advent of flexible endoscopic suturing.

Conventional clips vs over-the-scope-clips for the closure of the entry site in POEM and G-POEM procedures

BACKGROUND

new alternatives for entry site closure (ESC) in per-oral endoscopy myotomy (POEM) and gastric peroral endoscopy myotomy (G-POEM) have appeared.

OBJECTIVE

to compare the over-the-scope-clip (OTSC®) and conventional clips (CC) for ESC in POEM and G-POEM.

MATERIAL AND METHODS

a retrospective review of a prospective POEM and G-POEM database was performed between January 2015 and August 2019. A description was made of outcomes, using either OTSC® or CC for submucosal tunnel closure.

RESULTS

forty-six POEM and 26 G-POEM were included in the study (23/13 per group [CC/OTSC®]). There were no clinical or procedure differences. ESC was performed with 1 OTSC® vs 5 CC and 1 vs 6 (p = 0.01) for POEM and G-POEM, respectively. Adverse events associated with clips were 21.7% vs 13% (p = 0.01) and 7.7% vs 0% (p = 0.02) for CC and OTSC® in POEM and G-POEM, respectively.

CONCLUSION

OTSC® represents a safe and effective alternative for entry site closure in POEM and G-POEM cases. Further studies are needed to recommend OTSC® as the first option for submucosal tunnel closure in these procedures.

Staple Line Leaks Following Laparoscopic Sleeve Gastrectomy: Low Efficacy of the Over-the-Scope Clip

PURPOSE

The over-the-scope clip (OTSC) enables non-surgical management of gastrointestinal defects. The aim of this study was to report our experience with OTSC for patients with staple line leaks following laparoscopic sleeve gastrectomy (LSG).

MATERIALS AND METHODS

A prospectively maintained IRB-approved institutional database was queried for all patients treated with OTSC for staple line leaks following LSG from 2010 to 2018. Primary outcome was complete resolution of leak following OTSC. Secondary outcome was the number of additional procedures needed following OTSC.

RESULTS

Twenty-six patients (13 males, 13 females) were treated with OTSC for staple line leaks following LSG. The median age was 35 years (range 18-62), and mean body mass index was 44 kg/m2. The median time from index operation to leak diagnosis and from leak diagnosis to OTSC was 18 days (range 2-118), and 6 days (range 1-120), respectively. The initial endoscopic treatment was OTSC (n = 19), stent (n = 5), clip (n = 1), and clip and biologic glue (n = 1). OTSC alone led to final resolution of leak in 8 patients (31%) within 43 days of clip deployment (range 5-87). Five leaks resolved after a combination of OTSC and stent (19%) and one leak (4%) resolved after endoscopic suturing following a failed OTSC. Eleven patients (42%) failed endoscopic management and underwent total gastrectomy and esophagojejunostomy. One mortality (4%) was noted. The number of additional endoscopic sessions ranged from 1 to 10 (median 2).

CONCLUSIONS

OTSC carries a low success rate for controlling staple line leaks following LSG.

Long-term outcomes of over-the-scope clip for refractory gastrointestinal diseases

BACKGROUND

The Over-The-Scope Clip (OTSC) can effectively treat refractory gastrointestinal diseases. However, most reports have focused on short-term effectiveness. We examined clinical outcomes of the deployed clips and long-term characteristics.

MATERIAL AND METHODS

Of 47 patients with OTSC treatment, 35 with follow-up periods of ≥3 months were retrospectively examined. The indications were 11 bleedings, 17 perforations, and seven fistulas. The observation period was defined as medium-term (3 to <12 months) or long-term (≥12 months). The primary outcome was the clinical success rate without disease recurrence. The secondary outcomes were the complication rate, survival duration, and clip retention rate.

RESULTS

The medium- and long-term clinical success rates were 100% during the observation period (median, 44 months; range, 3-78 months). The complication rate was 2.9% (n = 1). The median survival time was 1,634 days for bleeding, 1,757 days for perforation, and 444 days for fistulas. The overall clip retention rates were 56.4%, 38.1%, 30.9%, and 25.9% after one, six, and 12 months and at the final follow-up, respectively. The average clip retention duration was 244 days in bleeding, 656 days in perforations, and 188 days in fistulas.

CONCLUSIONS

Regardless of clip detachment, the OTSC can be effective in long-term.

Use of over-the-scope clips in the colon in clinical practice: results from a German administrative database

BACKGROUND : The efficacy and safety of over-the-scope (OTS) clips in the colon is limited. This study aimed to evaluate OTS clip use in the colon in routine colonoscopy.

METHODS

Using administrative data from a large health insurance company, patients with OTS clip placement during colonoscopy were identified and analyzed by specific administrative codes. Indication for OTS clipping was analyzed, and follow-up was evaluated for surgical and repeat endoscopic interventions.

RESULTS

In 505 patients, indications for OTS clips were iatrogenic perforations (n = 80; Group A), polypectomy (n = 315; Group B), colonic bleeding (n = 51; Group C), and various underlying diseases (n = 59; Group D). In 11 Group A patients (13.8 %), surgical interventions occurred, mostly within 24 hours after clipping (n = 9), predominantly overstitching (n = 8). OTS clipping during polypectomy (Group B) was for complications (e. g. bleeding in 27 %) or was applied prophylactically. Only five patients required early surgery, three of whom had colorectal cancer. In four Group C patients (7.8 %), surgical resections were performed (persistent bleeding n = 1, colorectal cancer n = 2), while six patients underwent early repeat colonoscopy for recurrent bleeding. During further follow-up (days 11-30), 17 patients underwent resection for colonic neoplasms (n = 12) or persistent bleeding (n = 4), but only one case could be directly traced back to local OTS clip complication.

CONCLUSION

Colonic OTS clipping appears safe and effective in selected indications and complications in clinical routine but must be anatomically and technically feasible, avoiding overuse.

Recent advances in prevention and management of endoscopic retrograde cholangiopancreatography-related duodenal perforation

Endoscopic retrograde cholangiopancreatography (ERCP) is the main diagnosis and treatment for biliary and pancreatic diseases; however, ERCP requires a high level of technical skill and experience, and there is always a risk of complications. ERCP-related duodenal perforation is one of the most serious complications of ERCP, and although the incidence rate is relatively low, the mortality rate is high. Recently, the introduction of new classification methods and the development of endoscopic technology and equipment have made endoscopic therapy a new trend. This may change the management strategy of perforation. Therefore, we reviewed the latest developments in endoscopic management, surgical management, and conservative internal medicine management. In addition to introducing many new endoscope treatment methods, we also discussed the timing of interventions, the progress of endoscope and surgical indications, and corresponding prevention strategies. We aim to retrospectively analyse these treatment modalities to propose appropriate solutions to improve dynamic clinical therapy.

Efficacy and safety of endoscopic submucosal dissection using a scissors-type knife with prophylactic over-the-scope clip closure for superficial non-ampullary duodenal epithelial tumors

BACKGROUND AND STUDY AIM

This study aimed to assess the safety and feasibility of endoscopic submucosal dissection (ESD) using a scissors-type knife with prophylactic closure using over-the-scope clip (OTSC) for superficial non-ampullary duodenal epithelial tumors (SNADETs).

PATIENTS AND METHODS

Consecutive patients who underwent ESD for SNADETs >10 mm between January 2009 and July 2019 were retrospectively enrolled. We performed ESD using either a needle-type knife (Flush Knife-ESD) or a scissors-type knife (Clutch Cutter-ESD). Mucosal defects were prophylactically closed using three methods: conventional clip, laparoscopic closure, or OTSC.

RESULTS

A total of 84 lesions were resected using the Flush Knife-ESD and the Clutch Cutter-ESD (37 and 47 patients, respectively), and conventional clip, laparoscopic closure, and OTSC for mucosal defect closure after ESD were applied in 13, 13, and 56 lesions, respectively. The R0 resection rate was significantly higher in the Clutch Cutter-ESD than that in the Flush Knife-ESD (97.9% vs 83.8%, respectively, P = 0.040). The intraoperative perforation rate was significantly lower in the Clutch Cutter-ESD than in the Flush Knife-ESD (0% vs 13.5%, respectively, P = 0.014). Complete closure rates of conventional clip, laparoscopic closure, and OTSC were 76.9%, 92.3%, and 98.2%, respectively (P = 0.021); and delayed perforation rates were 15.4%, 7.7%, and 1.8%, respectively (P = 0.092).

CONCLUSIONS

Endoscopic submucosal dissection using a scissors-type knife with prophylactic OTSC closure is safe and feasible for the low-invasive treatment of SNADETs.

Diagnosis and management of iatrogenic endoscopic perforations: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement - Update 2020

1:  ESGE recommends that each center implements a written policy regarding the management of iatrogenic perforations, including the definition of procedures that carry a higher risk of this complication. This policy should be shared with the radiologists and surgeons at each center. 2 : ESGE recommends that in the case of an endoscopically identified perforation, the endoscopist reports its size and location, with an image, and statement of the endoscopic treatment that has been applied. 3:  ESGE recommends that symptoms or signs suggestive of iatrogenic perforation after an endoscopic procedure should be rapidly and carefully evaluated and documented with a computed tomography (CT) scan. 4 : ESGE recommends that endoscopic closure should be considered depending on the type of the iatrogenic perforation, its size, and the endoscopist expertise available at the center. Switch to carbon dioxide (CO2) endoscopic insufflation, diversion of digestive luminal content, and decompression of tension pneumoperitoneum or pneumothorax should also be performed. 5 : ESGE recommends that after endoscopic closure of an iatrogenic perforation, further management should be based on the estimated success of the endoscopic closure and on the general clinical condition of the patient. In the case of no or failed endoscopic closure of an iatrogenic perforation, and in patients whose clinical condition is deteriorating, hospitalization and surgical consultation are recommended.

Clinical outcomes of laparoscopic versus open surgery for repairing colonoscopic perforation: a multicenter study

PURPOSE

We conducted this study to compare the perioperative outcomes of laparoscopic surgery (LS) vs. open surgery (OS) for repairing colonoscopic perforation, and to evaluate the possible predictors of complications.

METHOD

We reviewed the medical records of patients who underwent surgical repair of colonoscopic perforation by LS or OS between January 2005 and June 2019 at six Hallym University-affiliated hospitals. Multivariable analysis was performed to identify the predictors of postoperative complications.

RESULTS

Of the total 99 patients, 40 underwent OS and 59 underwent LS. The postoperative hospital stay and the time to resuming a soft diet were shorter in the LS group than in the OS group (P = 0.017 and 0.026, respectively). The complication rate and Clavien-Dindo classification were not significantly different between the two groups. Multivariable analysis revealed that an American Society of Anesthesiologists score (ASA) ≥ 3 and switching from non-operative management to surgical treatment were independently associated with complications (P = 0.025 and 0.010, respectively).

CONCLUSION

LS may be a safe alternative to OS for repairing colonoscopic perforation with a shorter postoperative hospital stay and time to resuming a soft diet. Patients with an ASA score ≥ 3 and those with changes to their planned treatment should be monitored carefully to minimize their risk of complications.

Methods for Endoscopic Removal of Over-the-Scope Clip: A Systematic Review

AIMS

The over-the-scope clip (OTSC) has recently emerged as a new endoscopic device for treating gastrointestinal bleeding, perforations, fistulas, and leaks. A modified OTSC device (full-thickness resection device, FTRD) has been widely used for endoscopic full-thickness resection. However, there is less experience regarding the indications and methods for OTSC removal. We aimed to summarize the existing methods and indications for OTSC removal.

METHODS

We searched PubMed, Cochrane Library, and ClinicalTrials.gov to identify relevant publications on OTSC removal. The details of OTSC removal, including the methods, indications, success rates, adverse events, and failure causes, were extracted and summarized. A meta-analysis of pooled success rates was conducted using STATA 15.0.

RESULTS

Eighteen articles were included. The reported methods for OTSC removal included (1) grasping forceps, (2) the Nd : YAG laser, (3) argon plasma coagulation, (4) the remOVE system, (5) endoscopic mucosal resection/endoscopic submucosal dissection, and (6) ice-cold saline solution. Indications for OTSC removal were (1) poor healing, (2) OTSC misplacement, (3) repeat biopsy/therapy or further treatment, (4) adverse events after OTSC implantation, (5) removal after recovery, and (6) patient wishes. The pooled success rate of OTSC removal was 89% in patients treated with the remOVE system. Minor bleeding, superficial thermal damage, and superficial mucosal tears were common adverse events. Mucosal overgrowth was the main cause of OTSC removal failure.

CONCLUSIONS

The remOVE system is the best investigated method, with sufficient efficacy and safety for OTSC removal. This is the first systematic review of OTSC removal and provides significant guidance for clinical practice.

Guidewire-assisted over-the-scope clip delivery method into the distal intestine: a case series

BACKGROUND

The Over-the-scope clip (OTSC) has been recently introduced for multiple purposes, including refractory bleeding, perforation, fistula, and anastomotic dehiscence of the gastrointestinal tract. However, no easy access techniques for delivering OTSCs to distant sites have been described. Therefore, we have developed a simple and safe guidewire-assisted OTSC delivery (GOD) method for use on the distal intestine. This study aimed to investigate the technical feasibility and safety of the method.

MATERIAL AND METHODS

Between June 2018 and April 2019, all eight patients who underwent the GOD method were retrospectively examined. The primary outcome was the successful rate of OTSC delivery to the lesion without complications. The secondary outcomes were GOD procedure time, total procedure time, technical and clinical OTSC success rates, and GOD- and OTSC-associated complications.

RESULTS

The rate of successful OTSC delivery was 100%. The median procedure time of GOD was 21 min (range 8-29). The median total procedure time was 38.5 min (range 26-41). The technical and clinical success rates of OTSC were 100% and 75% (6/8), respectively. No GOD- or OTSC-associated complications occurred.

CONCLUSIONS

The GOD method is a feasible and safe technique for delivering OTSC toward the small and proximal large intestine.

Short-term outcomes of OTSC for anastomotic leakage after laparoscopic colorectal surgery

Introduction: There are several reports on the use of the over-the-scope clip (OTSC) for gastrointestinal bleeding/fistula and endoscopic iatrogenic perforation. However, there are almost no reports on OTSC use for anastomotic leakage (AL) after colorectal cancer surgery. The purpose of this study was to evaluate the outcome of AL closure using the OTSC.Material and methods: Five patients who had undergone AL after laparoscopic surgery for colorectal cancer from April 2017 to April 2019 were evaluated.Results: The average distance from the anal verge of the anastomosis site was 12 (5-18) cm. The average diameter of the dehiscent part was 10.9 (9.3-14.4) mm. The average number of OTSC days after the occurrence of AL was 11 (5-22). On the contrast examination immediately after OTSC, all cases were completely closed, but in the later contrast examination, only one case remained completely closed. The average incompletely closed diameter was 3.6 (2.9-5.1) mm, and the diameter of the dehiscent part was reduced in all cases. Only one patient ultimately underwent colostomy; the rest were cured with OTSC alone.Conclusion: AL site closure using the OTSC after colorectal cancer surgery is a useful minimally invasive treatment when combined with appropriate drain management.

Bowel Obstruction and Hydronephrosis Due to an Over-the-Scope Clip

An over-the-scope clip is a type of endoscopically placed clip used to treat gastrointestinal perforation, bleeding, or fistula. After the defect heals, the clip usually passes uneventfully through the gastrointestinal tract. An uncommon complication of over-the-scope clip placement is intestinal obstruction caused by luminal stenosis at the site of clip placement. Intestinal obstruction can rarely cause other downstream complications such as hydronephrosis from extrinsic compression of the urinary tract. We report a rare case of bilateral hydronephrosis caused by bowel obstruction from a migrated endoscopically placed clip.

Efficacy and safety of endoscopic full-thickness resection in the colon and rectum using an over-the-scope device: a meta-analysis

OBJECTIVE

Relevant publications were identified by searching PubMed, EMBASE, Cochrane Central Register of Controlled Trials and Web of Science before December 1, 2019. Studies in which ≥ 10 cases of colorectal lesions were resected with endoscopic full-thickness resection (EFTR) were included. Rates of efficacy (technical success (en bloc), full-thickness resection and R0 resection), rates of safety (bleeding, perforation and postpolypectomy syndrome) and rates of follow-up (residual/recurrent adenoma, fate of over-the-scope clip and surgery for any reason) were pooled and analyzed. Forest plots were graphed based on random effects models. Subgroup analyses and sensitivity analyses were also performed if significant heterogeneity existed.

RESULTS

A total of 469 patients across 9 studies were eligible for analysis. The pooled rates of technical success, full-thickness resection and R0 resection were 94.0% (95% CI 89.8-97.3%), 89.5% (83.9-94.2%) and 84.9% (75.1-92.8%), respectively. The pooled estimates of bleeding, perforation and postpolypectomy syndrome were 2.2% (95% CI 0.4-4.9%), 0.19% (95% CI 0.00-1.25%) and 2.3% (95% CI 0.1-6.3%), respectively. Finally, the pooled rates of residual/recurrent adenoma, fate of OTSC and surgery for any reason were 8.5% (95% CI 4.1-14.0%), 80.3% (95% CI 67.5-90.8%) and 6.3% (2.4-11.7%), respectively.

CONCLUSIONS

EFTR for nonlifting, invasive lesions in the colon and rectum appears to be effective and safe. However, future studies are necessary to explore the role of EFTR in large colorectal lesions and specify its indications.

Over-the-scope clip for acute esophageal variceal bleeding

Over-the-scope clip (OTSC) has been reported to control non-variceal bleeding; however, the use of this device for acute variceal hemorrhage (AVH) is very limited. We report our experience regarding the use of OTSC in patients with AVH in terms of technical success and safety. A retrospective clinical experience case series study was conducted from October 2017 to June 2019 at two tertiary care centers. Adult patients with AVH as a result of small varices managed with OTSC after endoscopic band ligation (EBL) failure were enrolled. Standard gastroscope and OTSC 'type a' with a cap of 11 mm in diameter were used in all procedures. Total of five patients with chronic liver disease (Child-Pugh score ≤8) and portal hypertension (hepatic venous pressure gradient, mean 14.4 ± 1.3 mmHg) were included. Four of them presented collapse of the bleeding varix, and one had wall disruption associated with fibrosis secondary to prior banding. We were able to stop AVH in all patients without clip-related adverse events during a 30-day follow-up period. Two patients developed solid food dysphagia after 3 months of clip deployment that resolved after removal using a bipolar cutting device. Twin grasper or anchor were not used to aid or facilitate the approximation of opposite edges in any patient. No additional local therapies or new endoscopic session for variceal eradication were required. This case series shows preliminary success controlling AVH with OTSC after EBL failure in patients with small varices. Esophageal dysphagia may appear as a complication during follow up but it can be resolved by clip removal.

Endoscopic Therapy for Acute Diverticular Bleeding

Diverticular bleeding accounts for approximately 26%–40% of the cases of lower gastrointestinal bleeding. Rupture of the vasa recta at the neck or dome of the diverticula can be the cause of this bleeding. Colonoscopy aids in not only the diagnosis but also the treatment of diverticular bleeding after a steady bowel preparation. Endoscopic hemostasis involves several methods, such as injection/thermal contact therapy, clipping, endoscopic band ligation (EBL), hemostatic powder, and over-the-scope clips. Each endoscopic method can provide a secure initial hemostasis. With regard to the clinical outcomes after an endoscopic treatment, the methods reportedly have no significant differences in the initial hemostasis and early recurring bleeding; however, EBL might prevent the need for transcatheter arterial embolization or surgery. In contrast, the long-term outcomes of the endoscopic treatments, such as a late bleeding and recurrent bleeding at 1 and 2 years, are not well known for diverticular bleeding. With regard to a cure for diverticular bleeding, there should be an improvement in both the endoscopic methods and the multilateral perspectives, such as diet, medicines, interventional approaches, and surgery.

Clips for managing perforation and bleeding after colorectal endoscopic mucosal resection

INTRODUCTION

The most commonly used treatment for advanced colorectal adenomas is endoscopic mucosal resection (EMR). The increased number of EMRs since the introduction of the screening program for colorectal cancer has resulted in an increase in EMR-related complications. This review summarizes the current knowledge for the use of clips for the treatment and prevention of complications after EMR.

AREAS COVERED

The historical development of clips is summarized and their properties are evaluated. An overview is presented of the evidence for therapeutic and prophylactic clipping for bleeding or perforation after EMR in the colon. Several clipping techniques are discussed in relation to the efficacy of wound closure. Furthermore, new techniques that will likely influence the use of clips in the future endoscopic practice, such as endoscopic full-thickness resection (eFTR) are also highlighted.

EXPERT COMMENTARY

Most research focuses on prophylactic clipping for delayed bleeding after EMR of large adenomas. We advocate a distance of 0.5-1.0 cm between aligning clips. This focus may likely shift from bleeding to perforation. Here, endoscopic treatment with through-the-scope clips and large-diameter clips may well replace surgery. The future role of clips will also depend on the further development of new endoscopic technologies, such as eFTR.

Efficacy of the OTSC System in the treatment of GI bleeding and wall defects: a PMCF meta-analysis

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.

Short-term outcomes of the over-the-scope clip proctology system for rectovaginal fistula repair: a prospective study

BACKGROUND

The over-the-scope clip proctology system is rather new and information regarding its use for the closure of anorectal fistulas is scarce. No study has been designed to focus exclusively on its application in the treatment of rectovaginal fistulas. The aim of the study was to evaluate the feasibility, safety, and effectiveness of the clip for rectovaginal fistula repair.

METHODS

From September 2014 to November 2017, consecutive patients underwent a rectovaginal fistula repair using the over-the-scope clip proctology system and were enrolled in a non-randomized prospective monocentric study. The primary outcome was fistula healing at 8 months. Secondary outcomes included assessment of morbidity and timing of rectovaginal fistula recurrence.

RESULTS

There were 16 patients with a median age of 40.1 years. The most common causes of rectovaginal fistula were adverse events following proctectomy or pelvic radiotherapy (6 patients), obstetric trauma (5 patients) and inflammatory bowel disease (3 patients). Most participants had undergone at least two previous surgical interventions before the clipping procedure. 11 patients had a temporary diverting stoma at time of the clipping procedure. Successful primary healing of the fistula was observed in 7 (43.7%) patients. Short-term complications were rare and included pain, which occurred in 4 patients, and spontaneous clip detachment, which occurred in 2 patients. Most recurrences appeared shortly after the procedure, with a median delay of 45 days (range 16-217).

CONCLUSIONS

We demonstrated the feasibility, safety, and reproducibility of the Over-The-Scope Clip Proctology system in rectovaginal fistula repair for the patients selected. Further trials should be designed, incorporating comparisons to well-established techniques, a longer follow-up period, and a larger cohort.

Adverse events related to colonoscopy: Global trends and future challenges

Colonoscopy is a widely used method for diagnosing and treating colonic disease. The number of colonoscopies is increasing worldwide, and concerns about associated adverse events are growing. Large-scale studies using big data for post-colonoscopy complications have been reported. A colon perforation is a severe complication with a relatively high mortality rate. The perforation rate, as reported in large studies (≥ 50,000 colonoscopies) published since 2000, ranges from 0.005-0.085%. The trend in the overall perforation rate in the past 15 years has not changed significantly. Bleeding is a more common adverse event than perforation. Recent large studies (≥ 50,000 colonoscopies) have reported post-colonoscopy bleeding occurring in 0.001-0.687% of cases. Most studies about adverse events related to colonoscopy were performed in the West, and relatively few studies have been conducted in the East. The incidence of post-colonoscopy complications increases in elderly patients or patients with inflammatory bowel diseases. It is important to use a unified definition and refined data to overcome the limitations of previous studies. In addition, a structured training program for endoscopists and a systematic national management program are needed to reduce post-colonoscopy complications. In this review, we discuss the current trends in colonoscopy related to adverse events, as well as the challenges to be addressed through future research.

Over-the-scope clip system: A review of 1517 cases over 9 years

Rescue therapy for gastrointestinal (GI) refractory bleeding, perforation, and fistula has traditionally required surgical interventions owing to the limited performance of conventional endoscopic instruments and techniques. An innovative clipping system, the over-the-scope clip (OTSC), may play an important role in rescue therapy. This innovative device is proposed as the final option in endoscopic treatment. The device presents several advantages including having a powerful sewing force for closure of GI defects using a simple mechanism and also having an innovative feature, whereby a large defect and fistula can be sealed using accessory forceps. Consequently, it is able to provide outstanding clinical effects for rescue therapy. This review clarifies the current status and limitations of OTSC according to different indications of GI refractory disease, including refractory bleeding, perforation, fistula, and anastomotic dehiscence. An extensive literature search identified studies reported 10 or more cases in which the OTSC system was applied. A total of 1517 cases described in 30 articles between 2010 and 2018 were retrieved. The clinical success rates and complications were calculated overall and for each indication. The average clinical success rate was 78% (n = 1517) overall, 85% for bleeding (n = 559), 85% (n = 351) for perforation, 52% (n = 388) for fistula, 66% (n = 97) for anastomotic dehiscence, and 95% (n = 122) for other conditions, respectively. The overall and severe OTSC-associated complications were 1.7% (n = 23) and 0.59% (n = 9), respectively. This review concludes that the OTSC system may serve as a safe and productive device for GI refractory diseases, albeit with limited success for fistula.

Choosing the right through-the-scope clip: a rigorous comparison of rotatability, whip, open/close precision, and closure strength (with videos)

BACKGROUND AND AIMS

Many new through-the-scope clips are available, and physicians often select clips based on physical characteristics and/or cost. However, functional profiles may be equally important and have not been methodically assessed. We evaluated 5 commercially available clips: Resolution 360, Instinct, Quick Clip Pro, Dura Clip, and SureClip.

METHODS

We rigorously compared clips on multiple characteristics, including rotatability, overshoot, open/close precision, and tensile/closure strength. Clips were tested in 4 different endoscope configurations: (1) straight, (2) duodenal sweep, (3) full retroflexion, and (4) across the duodenoscope elevator.

RESULTS

For rotatability, the Resolution 360 was the fastest due to its unique functionality in allowing primary MD control in rotation (P < .05). The Resolution 360, SureClip, and Dura Clip were able to rotate through the prescribed sequence across all scope configurations. For overshoot, the SureClip and Resolution 360 had the least overshoot for the straight configuration at 0%. All clips had >75% overshoot at more strained configurations. For open/close precision, the SureClip and Dura Clip showed precise opening/closing with the ability to stop at any point. The remaining clips exhibited abrupt opening with more controlled closure. For tensile strength, the Quick Clip Pro generated the highest peak force as would be required in lateral tissue manipulation (4.8 lb, P < .005). For closure strength, the Instinct overall showed the most gel compression, and along with the Resolution 360, showed 100% deployment success for all gel tissue thicknesses (up to 10 mm).

CONCLUSIONS

Each clip has a unique physical and functional profile, which may be a factor in selection depending on the clinical circumstance.

Esophagojejunal anastomotic leakage following gastrectomy for gastric cancer

Esophagojejunal anastomotic leakage (EJAL) is a serious complication of total or proximal gastrectomy for gastric cancer, with a reported incidence of 2.1-14.6% and mortality of up to 50%. EJAL is an independent prognostic factor for the poor survival of gastric cancer patients. Meticulous surgical techniques, experience with anastomotic devices, and a thorough understanding of various risk factors and preventive measures are essential and early diagnosis is critical for preventing EJAL-related death. Patients with suspected EJAL must be evaluated promptly, but contrast swallow is not recommended. There is no standard treatment strategy for EJAL, although conservative treatment with drainage and nutritional support is the most common approach. Effective endoscopic treatments have been reported but need further validation. Surgical treatment is associated with high mortality but should be considered to prevent death from suboptimal EJAL management, for patients with severe sepsis or when conservative treatment has failed.

The prepurse-string suture technique for gastric defect after endoscopic full-thickness resection (with video)

Endoscopic full-thickness resection (EFTR) is the main treatment for gastric tumors originating from the muscularis propria or gastric extra-luminal growth tumors. Successful closure of the gastric wall defect is a critical step during EFTR.The aim of this retrospective study was to evaluate the feasibility and safety of the endoscopic prepurse-string suture (p-EPSS) technique using an endoloop and several metallic clips during EFTR to close the perforation.Twenty-five patients with gastric tumors originated from the muscularis propria or with gastric extra-luminal growth tumors who received EFTR were analyzed at the Renmin Hospital of Wuhan University from June 2016 to May 2017. Patient characteristics, tumor characteristics, operation time length, and postoperative complications were evaluated in all patients.All the 25 patients underwent a successful EFTR. Complete closure of gastric defects was also achieved. The mean operation time length was 31 ± 14 minutes. The mean maximum size of tumor of was 1.7 ± 1.0 cm (range 0.5-4.5 cm). No severe postoperative complications occurred, such as massive bleeding, gastric leak, peritonitis, or abdominal abscess. No patient needed surgical intervention. Wounds were well healed 1 month after EFTR. No tumor metastasis and recurrence were observed during the follow-up period (median, 7 months).The p-EPSS technique using endoloop and several sterile repositionable hemostasis clips is safe and feasible for closing gastric perforation during EFTR.

Over-the-Scope Clips Are More Effective Than Standard Endoscopic Therapy for Patients With Recurrent Bleeding of Peptic Ulcers

BACKGROUND & AIMS

Endoscopic hemostasis is effective in treatment of bleeding peptic ulcers. However, rebleeding is difficult to treat and associated with substantial morbidity and mortality. We performed a prospective randomized trial to determine whether over-the-scope clips (OTSCs) are more effective than standard treatment of severe recurrent upper gastrointestinal bleeding.

METHODS

We performed our study at 9 academic referral centers (in Germany, Switzerland, and Hong Kong) from March 2013 through September 2016. Adult patients with recurrent peptic ulcer bleeding following initially successful hemostasis (66 patients in the intent-to-treat analysis) were randomly assigned to groups (1:1) that underwent hemostasis with either OTSC or standard therapy. Standard therapy was defined as hemostasis with through-the-scope clips (TTSC, n = 31) or thermal therapy plus injection with diluted adrenaline (n = 2). The primary endpoint was further bleeding (a composite endpoint of a persistent bleeding despite endoscopic therapy according to the protocol or recurrent bleeding within 7 days after successful hemostasis). Patients with further bleeding were allowed to cross over to OTSC therapy. Main secondary endpoints were mortality, necessity of surgical or angiographic salvage therapy, duration of stay in the hospital or intensive care, number of blood units transfused, and complications associated with endoscopic therapy.

RESULTS

Persistent bleeding after per-protocol hemostasis was observed in 14 patients (42.4%) in the standard therapy group and 2 patients (6.0%) in the OTSC group (P = .001). Recurrent bleeding within 7 days occurred in 5 patients (16.1%) in the standard therapy group vs 3 patients (9.1%) in the OTSC group (P = .468). Further bleeding occurred in 19 patients (57.6%) in the standard therapy group and in 5 patients (15.2%) in the OTSC group (absolute difference 42.4%; 95% confidence interval 21.6-63.2; P = .001) Within 30 days of follow-up, 1 patient in the standard therapy group (3.0%) and 1 patient in the OTSC group (3.0%) required surgical therapy (P = .999). Within 30 days of the procedure, 2 patients died in the standard therapy group (6.3%) and 4 patients died in the OTSC group (12.1%) (P = .672). There were no significant differences in the other secondary endpoints.

CONCLUSIONS

In prospective randomized trial, we found endoscopic treatment with OTSCs to be superior to standard therapy with TTSCs for patients with recurrent peptic ulcer bleeding. STING Study, Clinicaltrials.gov no: NCT1836900.

Therapeutic application of purse-string sutures with nylon loops and metal clips under single-channel endoscopy for repair of gastrointestinal wall defects

The present study was performed to evaluate the therapeutic safety and feasibility of purse-string sutures with nylon loops and metal clips under single-channel endoscopy to repair gastrointestinal wall defects that had previously developed during endoscopic full-thickness resection (EFR). A multicenter prospective cohort study of 42 patients who had developed defects of the gastrointestinal wall during EFR was conducted from April 2012 to October 2016. All lesions were endoscopically repaired with either a single-channel gastroscope (research group, n=18) or double-channel gastroscope (control group, n=24). The patients' clinical features, purse-string suturing times and complication rates were analyzed. There was no significant difference in the perforation rate between the research and control groups. There were also no significant differences in the purse-string suturing time (research vs. control group, 10.5 vs. 14.6 min, respectively; P=0.214), specimen size or complication rate (subcutaneous emphysema) between the two groups. No recurrences were observed during the follow-up period. The current data suggest that application of purse-string sutures with nylon loops and metal clips for repair of EFR-induced gastrointestinal wall defects may be safely and feasibly applied under single-channel gastroscopy as well as under double-channel gastroscopy.

Over-the-scope clip (OTSC®) closure of a recto-acetabular fistula

A 25-year-old male Syrian refugee presented in our hospital with recurrent hip infections after having undergone hip arthroplasty abroad following destruction of his right hip joint by shell splinters in the Syrian civil war. The patient underwent hip arthroplasty revision with implantation of a cement spacer. CT-scan with rectal contrast media filling revealed a recto-acetabular fistula. Consecutively, the patient underwent ileostomy formation. The fistula was then successfully closed by endoscopic over-the-scope clipping (OTSC^®). Fistulas between intestines and joints rarely develop and in the few cases published mostly extensive abdominal rescue surgery has been performed. Here, we present a case of a traumatic recto-acetabular fistula that was successfully closed by OTSC. This innovative method could represent a safe and suitable option to effectively close fistulas between joints and intestines thereby avoiding extensive rescue surgery with bowel resection or permanent ostomy.