Endoscopic closure of colon perforation with band ligation; salvage technique after endoclip failure

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.

Iatrogenic colon perforation during colonoscopy, diagnosis/treatment, and follow-up processes: A single-center experience

Objectives

latrogenic colon perforation (ICP) is one of the most feared complications of colonoscopy and causes unwanted morbidity and mortality. In this study, we aimed to discuss the characteristics of the cases of ICP we encountered in our endoscopy clinic, its etiology, our treatment approaches, and results in the light of the current literature.

Material and Methods

We retrospectively evaluated the cases of ICP among 9.709 lower gastrointestinal system endoscopy procedures (colonoscopy + rectosigmoidoscopy) performed for diagnostic purposes in our endoscopy clinic during 2002-2020.

Results

A total of seven cases of ICP were detected. The diagnosis was made during the procedure in six patients and after eight hours in one patient, and their treatment was performed urgently. Whereas surgical procedures were performed in all patients, the type of the procedure varied; laparoscopic primary repair was performed in two patients and laparotomy in five patients. In the patients who underwent laparotomy, primary repair was performed in three patients, partial colon resection and end-to-end anastomosis in one patient, and loop colostomy in one patient. The patients were hospitalized for an average of 7.14 days. The patients who did not develop complications in the postoperative follow-up were discharged with full recovery.

Conclusion

Prompt diagnosis and appropriate treatment of ICP is crucial to prevent morbidity and mortality.

Metal stent combined with ileus drainage tube for the treatment of delayed rectal perforation: A case report

BACKGROUND

Acute iatrogenic colorectal perforation (AICP) is a serious adverse event, and immediate AICP usually requires early endoscopic closure. Immediate surgical repair is required if the perforation is large, the endoscopic closure fails, or the patient's clinical condition deteriorates. In cases of delayed AICP (> 4 h), surgical repair or enterostomy is usually performed, but delayed rectal perforation is rare.

CASE SUMMARY

A 53-year-old male patient underwent endoscopic submucosal dissection (ESD) at a local hospital for the treatment of a laterally spreading tumor of the rectum, and the wound was closed by an endoscopist using a purse-string suture. Unfortunately, the patient then presented with delayed rectal perforation (6 h after ESD). The surgeons at the local hospital attempted to treat the perforation and wound surface using transrectal endoscopic microsurgery (TEM); however, the perforation worsened and became enlarged, multiple injuries to the mucosa around the perforation and partial tearing of the rectal mucosa occurred, and the internal anal sphincter was damaged. As a result, the perforation became more complicated. Due to the increased bleeding, surgical treatment with suturing could not be performed using TEM. Therefore, the patient was sent to our medical center for follow-up treatment. After a multidisciplinary discussion, we believed that the patient should undergo an enterostomy. However, the patient strongly refused this treatment plan. Because the position of the rectal perforation was relatively low and the intestine had been adequately prepared, we attempted to treat the complicated delayed rectal perforation using a self-expanding covered mental stent (SECMS) in combination with a transanal ileus drainage tube (TIDT).

CONCLUSION

For patients with complicated delayed perforation in the lower rectum and adequate intestinal preparation, a SECMS combined with a TIDT can be used and may result in very good outcomes.

[Endoscopic Band Ligation in Endoscopic Retrograde Cholangiopancreatography Related Duodenal Perforation]

Although ERCP is a therapeutic endoscopic procedure in pacreatico-biliary diseases, its rare complications, including pancreatitis, duodenal perforation, and bleeding, can be fatal. An 87-year-old woman with a history of gallbladder cancer presented with jaundice and general weakness. Her skin color was yellowish and epigastric tenderness was confirmed on a physical examination. On abdomen CT, the gallbladder cancer directly invaded the duodenum, common bile duct, and liver parenchyma. Enlarged portocaval lymph nodes obstructed the extrahepatic bile duct. ERCP was performed for bile duct decompression. When shortening of endoscopy was achieved, the duodenal lateral wall was perforated because of the endoscopic tip pressure. After inserting endoscopic retrograde biliary drainage and endoscopic nasobiliary drainage, endoclips were placed evenly around the defect, and a detachable snare was tightened around the endoclips. Three days later, the duodenal wall was not sealed on the abdomen CT scan. Repeat endoscopy was achieved, and the endoscopic nasobiliary drainage, endoscopic retrograde biliary drainage, endoclips, and detachable snare were removed. From the distal margin of the perforation, band ligation was performed, and a detachable snare was applied. The patient's condition improved after the second procedure. A percutaneous biliary stent was inserted, and she was discharged. This case highlights the successful endoscopic management of ERCP-related duodenal perforation.

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.

[Medical Dispute Related to Gastrointestinal Endoscopy Complications: Prevention and Management]

Because gastrointestinal (GI) endoscopy examinations are being performed increasingly frequently, the rate of detection of cancer and of precancerous lesions has increased. Moreover, development of more advanced endoscopic technologies has expanded the indications for, and thus frequency of, therapeutic endoscopic procedures. However, the incidence of complications associated with diagnostic or therapeutic GI endoscopy has also increased. The complications associated with GI endoscopy can be ameliorated by endoscopic or conservative treatment, but caution is needed as some of the more serious complications, such as perforation, can lead to death. In this chapter, we review the possible complications of GI endoscopy and discuss methods for their prevention and treatment.

Endoluminal closure of an unrecognized penetrating stab wound of the duodenum with endoscopic band ligation: A case report

BACKGROUND

A penetrating injury of a hollow viscus is an obvious indication for an exploratory laparotomy, but is not typically an indication for endoscopic treatment.

CASE SUMMARY

A 27-year-old man visited the emergency department with a self-inflicted abdominal stab wound. Injuries to the colon and ileum were detected, but an injury to the second portion of the duodenum was missed. On the day following admission to our institution, the patient became hemodynamically unstable with massive hematochezia, although there was no evidence of bleeding in the Levin tube or Jackson-Pratt drain. We thus performed an upper gastrointestinal endoscopy and discovered a missed duodenal injury that was actively bleeding. An endoscopic band ligation was performed for hemostasis and closure of the perforation. The patient was subsequently discharged without any complications.

CONCLUSION

A penetrating injury of the duodenum can be overlooked, so careful abdominal exploration is very important. If a missed duodenal injury is suspected, a cautious endoscopic approach may be helpful.

Endoscopic Management of Iatrogenic Colon Perforation

Colon perforations are difficult to resolve because they occur unexpectedly and infrequently. If the clinician is unprepared or lacks training in dealing with perforations, the clinical prognosis will be affected, which can lead to legal issues. We describe here the proper approach to the management of perforations, including deciding on endoscopic or surgical treatment, selection of endoscopic devices, endoscopic closure procedures, and general management of perforations that occur during diagnostic or therapeutic colonoscopy.

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.

Endoscopic closure of iatrogenic colon perforation using dual-channel endoscope with an endoloop and clips: methods and feasibility data (with videos)

BACKGROUND

Colon perforation is the most serious complication associated with colonoscopic procedures. We performed a novel purse-string suture technique to close the iatrogenic colonic perforation using dual-channel endoscope with an endoloop and clips.

METHODS

Iatrogenic colon perforations developed during diagnostic colonoscopy referred to a tertiary hospital over 10 years were considered for this endoscopic closure. An endoloop was inserted through the left channel of the endoscope and placed around the defect. The first clip was placed at the proximal site of the defect through the other channel of the endoscope, and the endoloop was anchored on the mucosa around the defect. Then, subsequent clips were placed next to previous clips and the endoloop was fixed. After the defect was encircled by the endoloop and clips, the rim of the opening was approximated by fastening the endoloop with a purse-string technique.

RESULTS

A total of 8 patients were admitted to our hospital because of iatrogenic colon perforations during diagnostic colonoscopy. Of these, 2 underwent laparoscopic surgery and 6 underwent endoscopic closure by this novel purse-string suture technique. The estimated diameters of the perforations were 20 mm. All cases were successfully treated in the endoscopy unit without sedation or general anesthesia, and recovered without any complication or subsequent operation. Abdominal pain had nearly resolved within 3 days after the procedure in all patients, and only mild peritonitis was observed.

CONCLUSIONS

Iatrogenic colon perforation can be treated with a purse-string suture technique using dual-channel endoscope with an endoloop and clips. This technique can be useful for relatively large colon perforations associated with diagnostic colonoscopy.

Endoscopic Band Ligation Is Able to Close Perforations Caused by Colonoscopy: A Porcine Model Study

Objective

Diagnostic colonoscopy is important for diagnosing colorectal diseases, including inflammatory bowel disease and colorectal tumours. Perforation during diagnostic colonoscopy, a rare but serious complication, is a considerable factor before performing the procedure. Immediate endoluminal closure of a perforation could prevent the adverse consequences associated with general anaesthesia and surgery. This study is aimed at assessing the potential effectiveness and safety of endoscopic band ligation (EBL) in closing a colon perforation during endoscopy in a porcine model.

Methods

Colon perforations were created and then subsequently closed with EBL in six porcine models. After 28 days of careful follow-up, pigs were euthanized for clinical and pathologic evaluations.

Results

All colon perforations were successfully closed using EBL in pigs. The mean time of perforation closure with EBL was 244.3 seconds with one to two bands, and there were no immediate complications or clinical manifestations of peritonitis or sepsis in any animals. No pericolonic abscess or peritonitis was found during necropsy. Histopathology demonstrated reepithelialization of the mucosa at the perforation site.

Conclusions

Immediate closure of perforations caused during colonoscopy with EBL is feasible and safe in a porcine model.

New devices and techniques for endoscopic closure of gastrointestinal perforations

Gastrointestinal perforations, which need to be managed quickly, are associated with high morbidity and mortality. Treatments used to close these perforations range from surgery to endoscopic therapy. Nowadays, with the development of new devices and techniques, endoscopic therapy is becoming more popular. However, there are different indications and clinical efficacies between different methods, because of the diverse properties of endoscopic devices and techniques. Successful management also depends on other factors, such as the precise location of the perforation, its size and the length of time between the occurrence and diagnosis. In this study, we performed a comprehensive review of various devices and introduced the different techniques that are considered effective to treat gastrointestinal perforations. In addition, we focused on the different methods used to achieve successful closure, based on the literature and our clinical experiences.

Comparing endoscopic mucosal resection with endoscopic submucosal dissection: the different endoscopic techniques for colorectal tumors

BACKGROUND

Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are used for the removal of colorectal tumors. There are no current guidelines or consensus on the optimal treatment strategy for these lesions. A meta-analysis was conducted to compare the effectiveness and safety of ESD and EMR for colorectal tumors.

METHODS

For the years 1966 until October 2014, Medline, PubMed, Scopus, Web of Science, and Cochrane Central Register of Controlled Trials were searched for articles comparing the effectiveness and safety of ESD and EMR. STATA 11.0 and RevMan 5.0 were used for meta-analysis and publication bias.

RESULTS

Seventeen articles were included in this meta-analysis. ESD was more effective than EMR in endoscopic complete resection rate (odds ratio [OR] = 2.81; 95% confidence interval [CI], 1.39-5.70; Z = 2.86; P = 0.004) and pathologic complete resection rate (OR = 2.81; 95% CI, 1.39-5.70; Z = 2.86; P = 0.004). ESD resulted in a higher perforation rate (OR = 5.27; 95% CI, 2.75-10.08; Z = 5.01; P < 0.00001) and a lower recurrence rate (OR = 0.14; 95% CI, 0.06-0.30; Z = 5.04; P < 0.00001). The tumor size was larger in the ESD group (OR = 3.09; 95% CI, 1.54-4.63; Z = 3.92; P < 0.0001), and the procedure time was longer in the ESD group (OR = 21.39; 95% CI, 10.33-32.46; Z = 3.79; P = 0.0002). But bleeding rate did not differ significantly (OR = 1.34; 95% CI, 0.81-2.20; Z = 1.14; P = 0.25). There was no publication bias analyzed by Begg test and Egger test.

CONCLUSIONS

The study indicates that ESD is the better treatment for colorectal tumors for its higher complete resection rate despite the longer procedure time and higher perforation rate.

Endoluminal Closure of Colon Perforation with Endoscopic Band Ligation: Technical Feasibility and Safety in an In Vivo Canine Model

BACKGROUND/AIMS

Endoscopic band ligation (EBL) is an accepted method in the management of variceal bleeding; however, there is little evidence on the safety and feasibility of EBL for the closure of bowel perforation. In this study, we aimed to evaluate the technical feasibility and efficacy of EBL in iatrogenic colon perforation by using a canine model.

METHODS

We established an iatrogenic colon perforation model by using seven beagle dogs. Longitudinal 1.5- to 1.7-cm colon perforations were created with a needle knife and an insulated-tip knife, and the perforation was subsequently closed with EBL. During a 2-week follow-up period, the animals were carefully monitored and then euthanized for pathologic examination.

RESULTS

The EBL of iatrogenic colon perforations was successful in all dogs. The mean procedure time for EBL closure with one to three bands was 191.7 seconds, and there were no immediate complications. One animal was euthanized after 3 days because of peritonitis. There were no clinical and laboratory features of sepsis or peritonitis in the remaining six animals. On necropsy, we did not find any fecal peritonitis, pericolonic abscess formation, or transmural dehiscence at the perforation site. Histopathology demonstrated inflamed granulation tissue and scar lesions replaced by fibrosis.

CONCLUSIONS

EBL might be a feasible and safe method for the management of iatrogenic colon perforations in an in vivo model.

Endoscopic Treatment of Gastrointestinal Perforations, Leaks, and Fistulae

Gastrointestinal leaks and fistulae are common postoperative complications, whereas intestinal perforation more commonly complicates advanced endoscopic procedures. Although these complications have classically been managed surgically, there exists an ever-expanding role for endoscopic therapy and the involvement of advanced endoscopists as part of a multidisciplinary team including surgeons and interventional radiologists. This review will serve to highlight the innovative endoscopic interventions that provide an expanding range of viable endoscopic approaches to the management and therapy of gastrointestinal perforation, leaks, and fistulae.

Endoscopic management of gastrointestinal perforations, leaks and fistulas

Gastrointestinal perforations, leaks and fistulas may be serious and life-threatening. The increasing number of endoscopic procedures with a high risk of perforation and the increasing incidence of leakage associated with bariatric operations call for a minimally invasive treatment for these complications. The therapeutic approach can vary greatly depending on the size, location, and timing of gastrointestinal wall defect recognition. Some asymptomatic patients can be treated conservatively, while patients with septic symptoms or cardio-pulmonary insufficiency may require intensive care and urgent surgical treatment. However, most gastrointestinal wall defects can be satisfactorily treated by endoscopy. Although the initial endoscopic closure rates of chronic fistulas is very high, the long-term results of these treatments remain a clinical problem. The efficacy of endoscopic therapy depends on several factors and the best mode of treatment will depend on a precise localization of the site, the extent of the leak and the endoscopic appearance of the lesion. Many endoscopic tools for effective closure of gastrointestinal wall defects are currently available. In this review, we summarized the basic principles of the management of acute iatrogenic perforations, as well as of postoperative leaks and chronic fistulas of the gastrointestinal tract. We also described the effectiveness of various endoscopic methods based on current research and our experience.

Closing perforations and postperforation management in endoscopy: duodenal, biliary, and colorectal

Early recognition of adverse events arising from endoscopy is essential. In some cases the injury can be viewed clearly during the procedure, and immediate action should be taken to repair the defect endoscopically if feasible. If perforation is unclear, imaging can be used to confirm the diagnosis. Surgical intervention is not always necessary; however, a surgical consultation for backup is essential. Selective cases can be managed conservatively or endoscopically with successful outcomes. Early recognition and intervention, input from specialist colleagues, and communication with the patient and family are keys to successfully managing the event.

Management of bleeding and perforation after colonoscopy

Bleeding is a relatively rare complication occurring mainly after snare polypectomy. The majority of cases can be managed successfully by endoscopic means leaving very few cases which will ultimately need an operation. Colonic perforation, on the other hand is a serious complication that requires intensive and careful management. Prompt recognition of the perforation during the procedure allows, in selected cases, immediate endoscopic closure with an uneventful and full recovery followed by close monitoring and surgical management in case of clinical deterioration. The criteria for the right selection of perforation cases amenable to endoscopic treatment do still need to be confirmed by prospective studies and further experience is required before a standard algorithm on the endoscopic management of perforations is developed.

Prompt management is most important for colonic perforation after colonoscopy

Purpose

The incidence of complications after colonoscopy is very low. The complications after colonoscopy that are of clinical concern are bleeding and perforation. The present study was conducted to determine the clinical outcomes and the risk factors of a colostomy or a colectomy after colonoscopic colon perforation.

Methods

From March 2009 to December 2012, the records of all patients who were treated for colorectal perforation after colonoscopy were reviewed retrospectively. The following parameters were evaluated: age, sex, purpose of colonoscopy, management of the colonic perforation, and interval from colonoscopy to the diagnosis of a colonic perforation. A retrospective analysis was performed to determine the risk factors associated with major surgery for the treatment of a colon perforation after colonoscopy.

Results

A total 27 patients were included in the present study. The mean age was 62 years, and 16 were males. The purpose of colonoscopy was diagnostic in 18 patients. The most common perforation site was the sigmoid colon. Colonic perforation was diagnosed during colonoscopy in 14 patients, just after colonoscopy in 5 patients, and 24 hours or more after colonoscopy in 8 patients. For the treatment of colonic perforation, endoscopic clipping was performed in 3 patients, primary closure in 15 patients, colon resection in 2 patients, Hartmann's procedures in 4 patients, and diverting colostomy in 3 patients. If the diagnosis of perforation after colonoscopy was delayed for more than 24 hours, the need for major treatment was increased significantly.

Conclusion

Although a colonic perforation after colonoscopy is rare, if the morbidity and the mortality associated with the colonic perforation are to be reduced, prompt diagnosis and management are very important.

Endoscopic band ligation for closure of GI perforations in a porcine animal model (with video)

BACKGROUND

GI perforations occur rarely during endoscopy but have life-threatening implications.

OBJECTIVE

To evaluate endoscopic band ligation (EBL) for closure of acute GI perforations by using a porcine model.

DESIGN

Investigator-initiated interventional pilot study by using an in vivo porcine model.

SETTING

Tertiary-care institution.

SUBJECTS

Ten domestic pigs.

INTERVENTION

Each animal underwent a single endoscopic procedure, with creation of a single GI lumen perforation. Perforations of 10 to 20 mm were created in the esophagus, stomach, duodenum, and colon. EBL was used for closure. Fourteen days later, the pigs were killed, microbial cultures were obtained, and histologic review was done.

MAIN OUTCOME MEASUREMENTS

Immediate and delayed endoscopic closure of the perforation site, evidence of clinical peritonitis during the 14-day follow-up.

RESULTS

Ten pigs completed the protocol and survived without clinical peritonitis during the 14-day follow-up. Endoscopic closure of a 15-mm esophageal perforation failed, thus, no attempt was made to close a 20-mm esophageal perforation. Closure of all other perforations was successful. At necropsy, fibrinous peritonitis was suspected in one animal with a 10-mm duodenal perforation. Chronic inflammation and fibroplasia at the perforation sites were the most common histologic findings.

LIMITATIONS

The applicability of widespread use in humans remains unknown despite successful case reports in the medical literature.

CONCLUSION

EBL can be used successfully to close 10 to 20 mm perforations within normal stomach, duodenum, and colon and can prevent clinically relevant intra-abdominal infections. However, for esophageal perforations, closure may be limited to small (≤10 mm), iatrogenic perforations.

Comparison of endoscopic band ligation and endoclip closure of colonic perforation: technical feasibility and efficacy in an ex vivo pig model

BACKGROUND AND AIM

Recent reports have indicated several instances of successful treatment of bowel perforation by using endoscopic band ligation (EBL) when treatment with endoclipping is unsuccessful, but this salvage method has not been investigated in any prospective model. Herein we aimed to compare the technical feasibility and efficacy of EBL and endoclip use in intraluminal closure of colon perforation, in an ex vivo model.

METHODS

Standardized colonic perforations were created using fresh porcine colon and subsequently closed by full-thickness interrupted sutures, endoclip (QuickClip2(TM)), or EBL. Each closure site was tested with compressed air by using a digital pressure monitor for evaluating leak pressure.

RESULTS

No significant differences were noted between the endoclip and EBL in leak pressures. Mean (± SD) pressures for air leakage from the perforations closed using the different devices were as follows: normal colon samples, 52.0 ± 13.2 mmHg; perforations closed with hand-sewn sutures, 32.3 ± 8.3 mmHg; perforations closed with endoclipping, 53.5 ± 22.7 mmHg; and perforations closed with EBL, 50.4 ± 12.5 mmHg. Time taken for closure by EBL was significantly less than that for closure by endoclipping (3.2 ± 1.7 min vs 6.8 ± 1.3 min, P < 0.01). Further, the number of devices used to achieve complete closure in the EBL group was lower than that with endoclipping (1.6 ± 0.5 vs 3.7 ± 0.8, P < 0.01).

CONCLUSION

Endoluminal closure of a 1.5-cm colon perforation with EBL decreased procedure time and was not inferior in leak pressure compared with endoclipping in this ex vivo porcine model.

Endoscopic clip closure of gastrointestinal perforations, fistulae, and leaks

Development of endoscopic devices to close perforations has certainly revolutionized endoscopy. Immediate closure of perforations eliminates the need for surgery, which allows us to push the limits of endoscopic surgery from the mucosal plane to deep submucosal layers and eventually transmurally. The present article focuses on endoscopic closure devices, closure techniques, followed by a review of animal and clinical studies on endoscopic closure of perforations.

Endoscopic band ligation: Beyond prevention and management of gastroesophageal varices

Endoscopic band ligation (EBL) is the preferred endoscopic technique for the endoscopic treatment of acute esophageal variceal bleeding. EBL has also been used to treat nonvariceal bleeding. Recently, Han et al demonstrated that EBL can be a feasible and safe alternate technique for the management of iatrogenic gastric perforation especially in cases in which closure with endoclips is difficult. EBL is technically simpler to perform than other methods and provides a good view of the lesions under direct pressure and suction from the transparent ligation cap. EBL can be used even if the diameter of the perforation is greater than 10 mm or if there is a severe tangential angle. In this commentary, we discuss the efficacy and safety of EBL for the closure of iatrogenic gastrointestinal perforation. We also discuss the advantages and disadvantages of EBL for the treatment of nonvariceal bleeding.

Successful endoscopic band ligation of esophageal perforation by fish bone ingestion

Acute esophageal perforations by foreign body ingestion result in complications such as mediastinitis and retropharyngeal or parapharyngeal abscesses. Because the mortality of esophageal perforation is up to 22%, immediate treatment is critical. Herein, we report a case of successful endoscopic band ligation of esophageal perforation. A 68-year-old man was admitted complaining of substernal pain and dysphagia after ingesting a fish bone. Immediately emergency endoscopy was performed, and the fish bone was observed lodged in the lower esophagus. Although the fish bone was easily removed by an endoscopic rat-tooth forceps, esophageal perforation was found after the procedure. Endoscopic band ligation for perforation was performed. Initial chest computed tomography (CT) showed pneumomediastinum and local inflammation, but follow-up CT showed improved pneumomediastinum. The patient was given oral nutrition 2 weeks after procedure, and he was discharged without any complications. This case report emphasizes for the first time the availability of immediate endoscopic band ligation for acute esophageal perforation.