Endoscopic placement of jejunal feeding tubes by using the Resolution clip: report of 2 cases

Endoscopic Management of Esophageal Perforations: Who, When, and How?

Esophageal perforations can be spontaneous or iatrogenic. Although they are a rare occurrence, they are associated with a significant morbidity and mortality. Traditionally, management of esophageal perforation consisted of surgery. However, endoscopic management is now emerging as the primary treatment modality and is less invasive and morbid than surgery. Endoscopic modalities include through-the-scope clips (TTS), over-the-scope clips (OTSC), placement of covered stents, and suturing. Suturing can be used for primary closure of the perforation as well as anchoring of stents to prevent migration. Smaller defects (<2 cm) can be closed with clips (TTS or OTSC), whereas larger defects require a stent placement or suturing to achieve closure. If the perforation is associated with a mediastinal collection, drainage is mandatory and can be done via CT-guided percutaneous drainage, surgery, or endoscopic vacuum therapy.

Which clip? A prospective comparative study of retention rates of endoscopic clips on normal mucosa and ulcers in a porcine model

BACKGROUND/AIM

There are currently no data on the relative retention rates of the Instinct clip, Resolution clip, and QuickClip2Long. Also, it is unknown whether retention rate differs when clips are applied to ulcerated rather than normal mucosa. The aim of this study is to compare the retention rates of three commonly used endoscopic clips.

MATERIALS AND METHODS

Six pigs underwent upper endoscopy with placement of one of each of the three types of clips on normal mucosa in the gastric body. Three mucosal resections were also performed to create "ulcers." Each ulcer was closed with placement of one of the three different clips. Repeat endoscopy was performed weekly for up to 4 weeks.

RESULTS

Only the Instinct and Resolution clips remained attached for the duration of the study (4 weeks). At each time point, a greater proportion of Instinct clips were retained on normal mucosa, followed by Resolution clips. QuickClip2Long had the lowest retention rate on normal mucosa. Similar retention rates of Instinct clips and Resolution clips were seen on simulated ulcers, although both were superior to QuickClip2Long. However, the difference did not reach statistical significance. All QuickClip2Long clips were dislodged at 4 weeks in both the groups.

CONCLUSIONS

The Resolution and Instinct clips have comparable retention rates and both appeared to be better than the QuickClip2Long on normal mucosa-simulated ulcers; however this did not reach statistical significance. Both the Resolution clip and the Instinct clip may be preferred in clinical situations when long-term clip attachment is required, including marking of tumors for radiotherapy and anchoring feeding tubes or stents. Either of the currently available clips may be suitable for closure of iatrogenic mucosal defects without features of chronicity.

Endoclips for fixation of nasoenteral feeding tubes: a review

BACKGROUND

Maintaining the position of an endoscopically placed nasoenteral feeding tube beyond the pylorus is often problematic because of retrograde migration. Fixation of a feeding tube to the small intestinal wall with an endoclip may prevent this. This article reviews available literature on the feasibility, efficacy and safety of endoclips for fixation of nasoenteral feeding tubes.

METHODS

A systematic search of the English literature was performed using MEDLINE, EMBASE and Cochrane databases to identify articles assessing the use of endoclips for fixation of feeding tubes, as well as articles assessing duration of attachment of endoclips.

RESULTS

Five cohort series were identified that evaluated the applicability of endoclips for fixation of feeding tubes to the small intestinal wall. In all patients, except one, a nasoenteral feeding tube could be successfully fixated to the small intestinal wall. During follow-up, no spontaneous migrations of feeding tubes were observed. No complications related to placement or removal of endoclips were observed. Three comparative studies evaluated duration of attachment of different types of endoclips to the gastrointestinal wall. Duration of attachment ranged from less than 1 week to more than 18 weeks, depending on the type of endoclip.

CONCLUSIONS

Based on available literature the use of endoclips for fixation of nasoenteral feeding tubes is feasible, effective and safe. Data from randomized controlled trials are needed.

Evaluating long-term attachment of two different endoclips in the human gastrointestinal tract

AIM: To evaluate the long-term attachment of two types of endoclips in the human gastrointestinal tract.

METHODS: In this prospective observational study, endoclips were placed and followed-up during endoscopies or using fluoroscopic images as part of a prospective feasibility study evaluating external beam radiotherapy (EBRT, wk 1-3) followed by high dose rate brachytherapy (HDRBT with an endoluminal applicator once a week for 3 wk, wk 9-11) in medically inoperablerectal cancer patients. Initially, the type and number of endoclips were chosenrandomly and later refined to 1 Resolution^® clip (Microvasive) proximal and 2 Quickclips^® (Olympus) distal to the tumor. Nine consecutive patients from between September 2007 and August 2008 were analyzed. Retention rates were evaluated over three different observational periods [period 1: pre-HDRBT (wk -2-8), period 2: during HDRBT (wk 9-11) and period 3: post-HDRBT (wk 12-16)].

RESULTS: In this study, a total of 44 clips were placed during endoscopy, either at the beginning or at the end of period 1. The Resolution clip had a higher overall retention rate than the Quickclip (P = 0.01). After a median period of 81 d after placement (in period 1), long-term retention rates for the Resolution clip and Quickclip clip were 67% and 35% respectively.

CONCLUSION: The Resolution clip has a high retention rate and is useful in situations where long-term attachment to the human gastrointestinal mucosa is warranted.

Prevention of covered enteral stent migration in patients with malignant gastric outlet obstruction: a pilot study of anchoring with endoscopic clips

OBJECTIVE

Placement of a self-expandable metal stent is a palliative treatment of choice for patients with malignant gastric outlet obstruction (GOO). Although covering an enteral stent with a membrane almost solves the problem of tumor ingrowth, stent migration continues to be a major unresolved problem. Our aim was to evaluate the clinical efficacy of endoscopic clipping for prevention of covered stent migration in the treatment of malignant GOO.

MATERIAL AND METHODS

A total of 25 consecutive patients with malignant GOO were evaluated prospectively. After deployment of a double-layered combination stent (comprising an outer uncovered stent and an inner covered stent), three endoscopic clips were applied for fixation of the proximal end of the enteral stent to the gastric or duodenal mucosa.

RESULTS

Technical and clinical success rates were 100% (25/25) and 88% (22/25), respectively. No stent migration was observed in any of the patients. Five patients (20%) experienced complications such as tumor overgrowth and stent compression.

CONCLUSION

Endoscopic clipping for enteral stent placement seems to be effective for prevention of covered stent migration in patients with malignant GOO.

Endoscopic clips prevent displacement of intestinal feeding tubes: a long-term follow-up study

BACKGROUND

Displacement of jejunal feeding tubes is a major problem in enteral feeding. Although endoscopic clips have been used to prevent migration of the tube during placement, the long-term effect of the clips on tube displacement is unknown.

OBJECTIVES

The purpose of this study was to examine the long-term effect of endoscopic clips on preventing displacement of the jejunal feeding tube.

DESIGN

A retrospective study.

SETTING

A single tertiary medical center.

MAIN OUTCOME MEASUREMENTS

The success rate of the procedure and the functional duration of the feeding tube.

RESULTS

About 93% of patients had a percutaneous endoscopic gastrostomy jejunal (PEGJ) tube successfully placed with use of endoscopic clips. About 7% had tube migration and repeat procedures were successful. The mean functional duration of the tube was 55 days. Limitations Retrospective, single-center.

CONCLUSIONS

Use of endoscopic clips can prevent migration during placement of the feeding tube and can also reduce tube displacement in the long term.

Endoscopic clipping

Endoscopic clips are relatively new devices that have been shown to be effective for the control of acute gastrointestinal hemorrhage. Various different models are available and offer simplicity of use with relatively few complications. Recently, endoscopic clips have been used for a variety of non-hemorrhagic conditions. In this article we review the literature and present current thinking about the indications, efficacy and safety of these devices.

Comparative study of endoscopic clips: duration of attachment at the site of clip application

BACKGROUND

Several designs of endoscopic clips are now commercially available, and the indications for endoclip application are rapidly expanding. However, very limited data have been published to aid in choosing between the different types of endoclips.

OBJECTIVE

To compare the duration of clip attachment between all commercially available endoclips.

SETTING

Long-term experiments on 50-kg pigs under general anesthesia.

DESIGN AND INTERVENTIONS

Upper endoscope was inserted into the stomach. One clip of each type (Resolution clip, TriClip, and HX-5L clip) was placed along the same gastric fold at a distance of 0.5 to 1 cm from each other. The animals were recovered. In pig nos. 1 and 2, repeat endoscopy was performed after 2 and 4 weeks. In pig nos. 3 to 5, endoscopy was repeated after 1, 2, and 5 weeks.

MAIN OUTCOME MEASUREMENTS

Duration of clip retention at the site of application.

RESULTS

In all animals, only the Resolution endoclip remained attached to the site of application for the entire duration of the study (4-5 weeks). No TriClips or HX-5L clips were attached at the 4- to 5-week follow-up endoscopies. Most of the TriClips (67%) detached within the first week after application. Most of the HX-5L clips (80%) dislodged within the first 2 weeks of follow-up.

LIMITATIONS

The study was performed in a porcine model with a small number of animals.

CONCLUSIONS

The Resolution clip has the longest duration of retention at the site of application (more than 4-5 weeks) and should be preferred when long-term attachment of endoclips is necessary.