OVESCO: un sistema prometedor de cierre endoscópico de las perforaciones del tracto digestivo

Endoscopic closure techniques of bariatric surgery complications: a meta-analysis

BACKGROUND

Leaks following bariatric surgery, while rare, are potentially fatal due to risk of peritonitis and sepsis. Anastomotic leaks and gastro-gastric fistulae following Roux-En-Y gastric bypass (RYGB) as well as staple line leaks after sleeve gastrectomy have historically been treated multimodally with surgical drainage, aggressive antibiotic therapy, and more recently, endoscopically. Endoscopic clipping using over-the-scope clips and endoscopic suturing are two of the most common approaches used to achieve full thickness closure.

METHODS

A systematic literature search was performed in PubMed to identify articles on the use of endoscopic clipping or suturing for the treatment of leaks and fistulae following bariatric surgery. Studies focusing on stents, and those that incorporated multiple closure techniques simultaneously, were excluded. Literature review and meta-analysis were performed with the PRISMA guidelines.

RESULTS

Five studies with 61 patients that underwent over-the-scope clip (OTSC) closure were included. The pooled proportion of successful closure across the studies was 81.1% (95% CI 67.3 to 91.7). The successful closure rates were homogeneous (I2 = 39%, p = 0.15). Three studies with 92 patients that underwent endoscopic suturing were included. The weighted pooled proportion of successful closure across the studies was shown to be 22.4% (95% CI 14.6 to 31.3). The successful closure rates were homogeneous (I2 = 0%, p = 0.44). Three of the studies, totaling 34 patients, examining OTSC deployment reported data for reintervention rate. The weighted pooled proportion of reintervention across the studies was 35.0% (95% CI 11.7 to 64.7). We noticed statistically significant heterogeneity (I2 = 68%, p = 0.04). One study, with 20 patients examining endoscopic suturing, reported rate of repeat intervention 60%.

CONCLUSION

Observational reports show that patients managed with OTSC were more likely to experience healing of their defect than those managed with endoscopic suturing. Larger controlled studies comparing different closure devices for bariatric leaks should be carried out to better understand the ideal endoscopic approach to these complications.

Hepatoduodenal fistula closure diagnosed and characterized Ecoendoscopically (EUS) and managed by OTSC CLIP OVESCO: A case report

Introduction

Gastrointestinal (GI) tract perforations are a significant source of morbidity in clinical practice; therefore, an early diagnosis is fundamental for early management. In management, surgery is the definitive therapy; however, there is evidence of a strong response to conservative measurements.

Presentation of case

A 53-year-old man known for a laparoscopic cholecystectomy with difficult access and postoperative complications was admitted to our emergency department due to a five-day clinical history comprising acute abdominal pain and feverish peaks up to 38.4 °C. Diagnosis methods CT and NMR were performed but did not lead to a clear diagnosis. Therefore, a EUS was performed observing an anechoic path that communicates the duodenal wall with a right subhepatic collection that was in contact with the proximal bile duct, thickening its walls. A 5 mm fistulous orifice was found. The hepatoduodenal fistula was close endoscopically with the over-the-scope-clip OVESCO OTSC. Post endoscopic closure course was uneventful.

Discussion

Duodenal fistulae are considered one of the most serious complications in gastrointestinal surgery, when conventional diagnosis methods do not permit the clinicians to get either a medical diagnosis or the management; the EUS can. Advances in interventional endoscopic techniques offer an alternative management for the closure of GI fistulae.

Conclusion

Whenever the presence of an organized fistula is clinically suspected, EUS can be considered a useful tool that allows not only the characterization of the fistulous path and but also the definition of the minimally invasive endoscopic treatment.

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Duodenal fistulae are considered one of the most serious complications in gastrointestinal surgery.

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Whenever the presence of an organized intestinal fistula is clinically suspected, EUS can be considered a useful tool that allows characterizing the fistulous path and defining the minimally invasive endoscopic treatment.

Endoscopic closure of gastrointestinal perforations and fistulas using the Ovesco Over-The-Scope Clip system at a tertiary care hospital center

INTRODUCTION AND AIM

Enteric perforations and fistulas are difficult to manage due to comorbidities, poor nutritional status, and anatomic challenges related to multiple interventions in those patients. The use of endoscopic methods as a nonsurgical approach is increasing. The aim of the present study was to describe the clinical experience with the use of the Ovesco Over-The-Scope Clip system in the closure of perforations, fistulas, and other indications in the digestive tract at a tertiary care hospital center.

MATERIALS AND METHODS

A case series was carried out on patients that underwent lesion closure with the Ovesco clip, within the time frame of January 2015 to December 2017.

RESULTS

The Ovesco clip was used for closure in 14 patients ranging in age from 21-90 years, with different indications: iatrogenic perforations; anastomotic leaks and fistulas; tracheoesophageal fistulas; and esophagogastric perforation. Technical success was achieved in 100% of the patients and clinical success in 78.57%. No complications were reported.

CONCLUSIONS

The Ovesco Over-The-Scope Clip system is a safe and effective method for managing gastrointestinal acute perforations and fistulas.

Endoscopic closure of tracheoesophageal fistula for tuberculosis with an over-the-scope-clip

Surgical management has been the main approach for enteral fistulae. This approach is usually complex due to comorbidities, a wasted nutritional state and anatomical difficulties related to prior multiple interventions. Therefore, endoscopic methods such as clips, self-expanding metal stent (SEMS) and recently, the over scope clip (OTSC®) are increasing in popularity and use. Herein, we present the case of a patient with a HIV infection who was admitted due to respiratory symptoms. Radiological and microbiological studies documented a tracheoesophageal fistula due to tuberculosis (TB) and cytomegalovirus (CMV) infection. Therefore, an esophageal fully-covered stent was placed, which migrated into the stomach. The thoracic surgeons considered an esophagectomy with gastric ascent and muscle patch in the trachea. However, due to his poor nutritional status and comorbidity, an OTSC was placed to treat the fistulae. The patient also received medical treatment with anti-tuberculotics and anti-retrovirals.

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.

Flexible and capsule endoscopy for screening, diagnosis and treatment

Endoscopy dates back to the 1860s, but many of the most significant advancements have been made within the past decade. With the integration of robotics, the ability to precisely steer and advance traditional flexible endoscopes has been realized, reducing patient pain and improving clinician ergonomics. Additionally, wireless capsule endoscopy, a revolutionary alternative to traditional scopes, enables inspection of the digestive system with minimal discomfort for the patient or the need for sedation, mitigating some of the risks of flexible endoscopy. This review presents a research update on robotic endoscopic systems, including both flexible scope and capsule technologies, detailing actuation methods and therapeutic capabilities. A future perspective on endoscopic potential for screening, diagnostic and therapeutic gastrointestinal procedures is also presented.

Endoscopic treatment of iatrogenic gastrointestinal perforations: an overview

In the past, the treatment of iatrogenic gastrointestinal perforations was limited to surgical management or to medical observation. Natural Orifice Transluminal Endoscopic Surgery (NOTES) has paved the way towards the development of reliable endoscopic closure techniques, which can be applicable in accidental perforations of the gastrointestinal tract. When endoscopic treatment is feasible, hemoclips are preferred in smaller perforations, while over-the-scope-clips or a combination of hemoclips, endoloops, and glue are used in larger ones. Endoscopic stitching is rarely utilized, and endoscopic stapling has been practically abandoned. The use of self-expandable covered stents can be considered in the esophagus and duodenum. Broad spectrum antibiotics are recommended in most cases. Clinical follow-up in a medico-surgical unit is mandatory and surgical intervention should not be delayed more than 24h if clinical or biological worsening occurs. Imaging with oral contrast medium is advisable before resumption of oral feeding in the case of large perforations.