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Minakari M, Sedaghat N. Endoscopic clipping of a complicated esophageal perforation following pneumatic dilation for achalasia: A case study and literature review. Clin Case Rep 2022; 10:e6620. [PMID: 36447673 PMCID: PMC9701890 DOI: 10.1002/ccr3.6620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 10/18/2022] [Accepted: 11/04/2022] [Indexed: 11/29/2022] Open
Abstract
A transmural esophageal tear complicated by large size and unusual location was diagnosed in a 59-year-old man after undergoing pneumatic balloon dilation for achalasia. It was closed with six endo-clips. The patient recovered and was discharged with ordinary diet 8 days later, after receiving supportive care for a week.
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Affiliation(s)
- Mohammad Minakari
- Division of Gastroenterology, Department of Internal Medicine, School of MedicineIsfahan University of Medical SciencesIsfahanIran
| | - Nahad Sedaghat
- School of MedicineIsfahan University of Medical SciencesIsfahanIran
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Paspatis GA, Arvanitakis M, Dumonceau JM, Barthet M, Saunders B, Turino SY, Dhillon A, Fragaki M, Gonzalez JM, Repici A, van Wanrooij RLJ, van Hooft JE. Diagnosis and management of iatrogenic endoscopic perforations: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement - Update 2020. Endoscopy 2020; 52:792-810. [PMID: 32781470 DOI: 10.1055/a-1222-3191] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Gregorios A Paspatis
- Gastroenterology Department, Venizelion General Hospital, Heraklion, Crete-Greece
| | - Marianna Arvanitakis
- Gastroenterology, Hepatopancreatology, and Digestive Oncology, Erasme Hospital, Universite Libre de Bruxelles, Brussels, Belgium
| | - Jean-Marc Dumonceau
- Gastroenterology Service, Centre Hospitalier Universitaire de Charleroi, Charleroi, Belgium
| | | | - Brian Saunders
- St Mark's Hospital, Wolfson Unit for Endoscopy, North West London Hospitals University Trust, Harrow, London, UK
| | | | - Angad Dhillon
- St Mark's Hospital, Wolfson Unit for Endoscopy, North West London Hospitals University Trust, Harrow, London, UK
| | - Maria Fragaki
- Gastroenterology Department, Venizelion General Hospital, Heraklion, Crete-Greece
| | | | - Alessandro Repici
- Department of Gastroenterology, Digestive Endoscopy Unit, IRCCS Istituto Clinico Humanitas, Milan, Italy
| | - Roy L J van Wanrooij
- Department of Gastroenterology and Hepatology, AG&M Research Institute, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, The Netherlands
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Endoscopic management of iatrogenic gastrointestinal perforations. LAPAROSCOPIC, ENDOSCOPIC AND ROBOTIC SURGERY 2019. [DOI: 10.1016/j.lers.2019.05.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
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Abstract
OPINION STATEMENT Esophageal leaks (EL) and ruptures (ER) are rare conditions associated with a high risk of mortality and morbidity. Historically, EL and ER have been surgically treated, but current treatment options also include conservative management and endoscopy. Over the last decades, interventional endoscopy has evolved as an effective and less invasive alternative to primary surgery in these cases. A variety of techniques are currently available to re-establish the continuity of the digestive tract, prevent or treat infection related to the leak/rupture, prevent further contamination, drain potential collections, and provide nutritional support. Endoscopic options include clips, both through the scope (TTS) and over the scope (OTS), stent placement, vacuum therapy, tissue adhesive, and endoscopic suturing techniques. Theoretically, all of these can be used alone or with a multimodality approach. Endoscopic therapy should be combined with medical therapy but also with percutaneous drainage of collections, where present. There is robust evidence suggesting that this change of therapeutic paradigm in the form of endoscopic therapy is associated with improved outcome, better quality of life, and shortened length of hospital stay. Moreover, recent European guidelines on endoscopic management of iatrogenic perforation have strengthened and to some degree regulated and redefined the role of endoscopy in the management of conditions where there is a breach in the continuity of the GI wall. Certainly, due to the complexity of these conditions and the variety of available treatment options, a multidisciplinary approach is strongly recommended, with close clinical monitoring (by endoscopists, surgeons, and intensive care physicians) and special attention to signs of sepsis, which can lead to the need for urgent surgical management. This review article will critically discuss the literature regarding endoscopic modalities for esophageal leak and perforation management and attempt to place them in perspective for the physician.
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Devaraj P, Gavini H. Endoscopic management of postoperative fistulas and leaks. GASTROINTESTINAL INTERVENTION 2017. [DOI: 10.18528/gii160032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Prathab Devaraj
- Department of Gastroenterology, Hepatology, and Nutrition, Banner University Medical Center, Tucson, AZ, USA
| | - Hemanth Gavini
- Department of Gastroenterology, Hepatology, and Nutrition, Banner University Medical Center, Tucson, AZ, USA
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Sun B, Guo J, Ge N, Sun S, Wang S, Liu X, Wang G, Feng L. Endoscopic ultrasound-guided puncture suture device versus metal clip for gastric defect closure after endoscopic full-thickness resection: A randomized, comparative, porcine study. Endosc Ultrasound 2016; 5:263-8. [PMID: 27503160 PMCID: PMC4989409 DOI: 10.4103/2303-9027.187891] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objective: The secure closure of the wall defect is a critical stage of endoscopic full-thickness resection (EFTR). The aim of this study was to compare the closure of post-EFTR defects using an endoscopic ultrasound-guided puncture suture device (PSD) with the metal clip (MC) technique in a randomized, comparative, porcine study. Methods: We performed a randomized comparative survival study that included 18 pigs. The circular EFTR defects with a diameter of approximately 20 mm were closed with either a PSD or MC. Serum levels of interleukin-6 (IL-6) were determined preoperatively and on a postoperative day (POD) 1, 3, and 7. Three animals from each group were sacrificed at the end of the 7th, 14th, and 30th POD. Tissue samples retrieved from the closure sites were examined macroscopically and microscopically. Results: Resection and closure were performed in 18 pigs (100%) without major perioperative complications. The mean closure time was significantly longer in the MC group than in the PSD group (25.00 ± 3.16 min vs. 1.56 ± 0.39 min; P < 0.05). Preoperative and POD 7 serum levels of IL-6 did not differ between the two groups. However, on POD 1, the IL-6 levels were observed to be significantly greater in the MC group than in the PSD group (P < 0.005). No significant differences between the PSD and MC groups were observed at necropsy. Conclusion: In this in vivo porcine model, PSD is a feasible device that achieves post-EFTR defect closure with a much shorter closure time and with less immunological responses than the MC technique.
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Affiliation(s)
- Beibei Sun
- Endoscopy Center, Shengjing Hospital, China Medical University, Liaoning Province, China
| | - Jintao Guo
- Endoscopy Center, Shengjing Hospital, China Medical University, Liaoning Province, China
| | - Nan Ge
- Endoscopy Center, Shengjing Hospital, China Medical University, Liaoning Province, China
| | - Siyu Sun
- Endoscopy Center, Shengjing Hospital, China Medical University, Liaoning Province, China
| | - Sheng Wang
- Endoscopy Center, Shengjing Hospital, China Medical University, Liaoning Province, China
| | - Xiang Liu
- Endoscopy Center, Shengjing Hospital, China Medical University, Liaoning Province, China
| | - Guoxin Wang
- Endoscopy Center, Shengjing Hospital, China Medical University, Liaoning Province, China
| | - Linlin Feng
- Endoscopy Center, Shengjing Hospital, China Medical University, Liaoning Province, China
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Angsuwatcharakon P, Rerknimitr R. Endoscopic closure of iatrogenic perforation. INTERNATIONAL JOURNAL OF GASTROINTESTINAL INTERVENTION 2016. [DOI: 10.18528/gii150009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
- Phonthep Angsuwatcharakon
- Department of Anatomy, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Rungsun Rerknimitr
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
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Schmidt A, Fuchs KH, Caca K, Küllmer A, Meining A. The Endoscopic Treatment of Iatrogenic Gastrointestinal Perforation. DEUTSCHES ARZTEBLATT INTERNATIONAL 2016; 113:121-8. [PMID: 26976712 DOI: 10.3238/arztebl.2016.0121] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 10/05/2015] [Accepted: 10/05/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Iatrogenic gastrointestinal perforation is a life-threatening complication that arises very rarely in routine endoscopic procedures, with an incidence of 0.03-0.8%. It is more likely in highly complex and invasive therapeutic interventions. In certain situations, endoscopic closure of the perforation and treatment with antibiotics can obviate the need for emergency surgical repair. METHODS This review is based on pertinent articles retrieved by a selective literature search in PubMed and on a relevant position paper. RESULTS Existing clinical studies of treatment for iatrogenic gastrointestinal perforation are mainly retrospective and uncontrolled. No randomized and controlled trials have been performed to date. If the perforation is discovered soon after it arises, endoscopic treatment can be considered. Gastrointestinal perforations that are less than 30 mm in size can be closed with a clip. In the esophagus, expanding metal stents can be used as well. Clip application is successful in 80-100% of cases of gastrointestinal perforation, and the perforation remains permanently closed in 60-100% of cases. Reports on the endoscopic treatment of esophageal perforation show mixed results, with closure rates of roughly 90% and clinical success rates of roughly 80%. If endoscopic treatment is not possible, timely laparoscopic or open surgical repair is needed. CONCLUSION The endoscopic treatment of iatrogenic perforations is safe and reliable. Success depends on early detection, adequate endoscopic closure with properly mastered technique, and the early initiation of concomitant antibiotic treatment, which must be continued for a full course. Most patients who are treated in this way do not need emergency surgery.
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Affiliation(s)
- Arthur Schmidt
- Department of Internal Medicine, Gastroenterology and Oncology, Klinikum Ludwigsburg, Department of General, Visceral and Thoracic Surgery,, AGAPLESION Markus Krankenhaus Frankfurt am Main, Ulm University Hospital Medical Center, Department of Internal Medicine I
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Lázár G, Paszt A, Mán E. Role of endoscopic clipping in the treatment of oesophageal perforations. World J Gastrointest Endosc 2016; 8:13-22. [PMID: 26788259 PMCID: PMC4707319 DOI: 10.4253/wjge.v8.i1.13] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 09/25/2015] [Accepted: 11/11/2015] [Indexed: 02/06/2023] Open
Abstract
With advances in endoscopic technologies, endoscopic clips have been used widely and successfully in the treatment of various types of oesophageal perforations, anastomosis leakages and fistulas. Our aim was to summarize the experience with two types of clips: The through-the-scope (TTS) clip and the over-the-scope clip (OTSC). We summarized the results of oesophageal perforation closure with endoscopic clips. We processed the data from 38 articles and 127 patients using PubMed search. Based on evidence thus far, it can be stated that both clips can be used in the treatment of early (< 24 h), iatrogenic, spontaneous oesophageal perforations in the case of limited injury or contamination. TTS clips are efficacious in the treatment of 10 mm lesions, while bigger (< 20 mm) lesions can be treated successfully with OTSC clips, whose effectiveness is similar to that of surgical treatment. However, the clinical success rate is significantly lower in the case of fistulas and in the treatment of anastomosis insufficiency. Tough prospective randomized multicentre trials, which produce the largest amount of evidence, are still missing. Based on experience so far, endoscopic clips represent a possible therapeutic alternative to surgery in the treatment of oesophageal perforations under well-defined conditions.
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Affiliation(s)
- Annette Fritscher-Ravens
- Experimental Endoscopy Unit, Department of Internal Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Germany,Corresponding author Annette Fritscher-Ravens Experimental Endoscopy Unit, Department of Internal Medicine, University Hospital Schleswig-HolsteinCampus Kiel24105 KielGermany
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Abstract
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.
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Yılmaz B, Unlu O, Roach EC, Can G, Efe C, Korkmaz U, Kurt M. Endoscopic clips for the closure of acute iatrogenic perforations: Where do we stand? Dig Endosc 2015; 27:641-8. [PMID: 25919698 DOI: 10.1111/den.12482] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 04/06/2015] [Accepted: 04/22/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIM Iatrogenic perforation of the gut during endoscopy remains an uncommon but critical complication with significant morbidity and probable mortality than usual surgical treatment. Some authors have adopted a non-surgical closure method in chosen cases and, since 1993, endoclips have been used to close perforation in the stomach. The endoscopic practice of endoclips has been commonly used in the gut for hemostasis. Currently, the use of endoscopic techniques is increasing for the closure of endoscopic submucosal dissection or endoscopic mucosal resection. Endoscopic perforations that improved with endoscopic closure in the literature prior to 2008 have been previously described. In the present article, we present a descriptive review of cases with iatrogenic perforation in the gut treated with endoclips between 2008 and 2014. METHODS Comprehensive literature screening and a systematic review using PubMed and Medline was done for all reports published between January 2008 and December 2014 using the endoclip technique in the closure of iatrogenic perforations. RESULTS A total of 47 studies published between 2008 and 2014 using endoclips for the closure of iatrogenic perforations of the gut (nine esophagus, 11 stomach, 15 duodenum, 12 colon and rectum) were found. All studies were explained briefly and summarized in a table. CONCLUSIONS There is strong evidence to show the efficacy of endoclips in the management of iatrogenic perforations, especially when recognized early. Limitations of endoclipping such as inefficiency against large perforations may be overcome by improving novel techniques in the future.
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Affiliation(s)
- Bulent Yılmaz
- Department of Gastroenterology, Bolu Izzet Baysal Education and Research Hospital, Bolu
| | - Ozan Unlu
- Department of Gastroenterology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | | | - Guray Can
- Department of Gastroenterology, Bolu Izzet Baysal Education and Research Hospital, Bolu
| | - Cumali Efe
- Department of Gastroenterology, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Ugur Korkmaz
- Department of Gastroenterology, Bolu Izzet Baysal Education and Research Hospital, Bolu
| | - Mevlut Kurt
- Department of Gastroenterology, Bolu Izzet Baysal Education and Research Hospital, Bolu
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Schmidt A, Meier B, Caca K. Endoscopic full-thickness resection: Current status. World J Gastroenterol 2015; 21:9273-9285. [PMID: 26309354 PMCID: PMC4541380 DOI: 10.3748/wjg.v21.i31.9273] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2015] [Revised: 05/16/2015] [Accepted: 07/03/2015] [Indexed: 02/06/2023] Open
Abstract
Conventional endoscopic resection techniques such as endoscopic mucosal resection or endoscopic submucosal dissection are powerful tools for treatment of gastrointestinal neoplasms. However, those techniques are restricted to superficial layers of the gastrointestinal wall. Endoscopic full-thickness resection (EFTR) is an evolving technique, which is just about to enter clinical routine. It is not only a powerful tool for diagnostic tissue acquisition but also has the potential to spare surgical therapy in selected patients. This review will give an overview about current EFTR techniques and devices.
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Endoluminal flexible endoscopic suturing for minimally invasive therapies. Gastrointest Endosc 2015; 81:262-9.e19. [PMID: 25440675 DOI: 10.1016/j.gie.2014.09.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 09/03/2014] [Indexed: 12/12/2022]
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Cap-assisted clip closure of large esophageal perforations caused by a duodenoscope during endoscopic retrograde cholangiopancreatography (with video). Surg Laparosc Endosc Percutan Tech 2015; 24:e101-5. [PMID: 24710255 DOI: 10.1097/sle.0b013e318293c4b6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
BACKGROUND/AIMS Esophageal perforation is a rare complication of endoscopic retrograde cholangiopancreatography and the perforation is usually too large to close with endoclips. We developed an endoscopic procedure for the perforations. METHODS A gastroscope fitted with a cap was inserted into the esophagus to perform the clip closure. The closure procedure was divided in 3 steps: step 1 is large clip closure; step 2 is small clip closure; and step 3 is the nasogastric tube placement for drainage. RESULTS A total of 4 patients underwent a cap-assisted clip closure and the procedures were completed successfully within 30 minutes. The cure was achieved in all the 4 patients after a relatively short period of hospital stay and no patient complained of closure-related complication. CONCLUSIONS The cap-assisted clip closure procedure is effective, safe, and easy to carry out for the closure of large esophageal perforations. It may also be applied to perform the closure of large perforations at other sites of the digestive tract.
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Feussner H, Becker V, Bauer M, Kranzfelder M, Schirren R, Lüth T, Meining A, Wilhelm D. Developments in flexible endoscopic surgery: a review. Clin Exp Gastroenterol 2014; 8:31-42. [PMID: 25565878 PMCID: PMC4278730 DOI: 10.2147/ceg.s46584] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Flexible endoscopy is increasingly developing into a therapeutic instead of a purely diagnostic discipline. Improved visualization makes early lesions easily detectable and allows us to decide ad hoc on the required treatment. Deep enteroscopy allows the exploration of even the small bowel - for long a "white spot" for gastrointestinal endoscopy - and to perform direct treatment. Endoscopic submucosal dissection is a considerable step forward in oncologically correct endoscopic treatment of (early) malignant lesions. Though still technically challenging, it is increasingly facilitated by new manipulation techniques and tools that are being steadily optimized. Closure of wall defects and hemostasis could be improved significantly. Even the anatomy beyond the gastrointestinal wall is being explored by the therapeutic use of endoluminal ultrasound. Endosonographic-guided surgery is not only a suitable fallback solution if conventional endoscopic retrograde cholangiopancreatography fails, but even makes necrosectomy procedures, abscess drainage, and neurolysis feasible for the endoscopist. Newly developed endoscopic approaches aim at formerly distinctive surgical domains like gastroesophageal reflux disease, appendicitis, and cholecystitis. Combined endoscopic/laparoscopic interventional techniques could become the harbingers of natural orifice transluminal endoscopic surgery, whereas pure natural orifice transluminal endoscopic surgery is currently still in its beginnings.
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Affiliation(s)
- Hubertus Feussner
- Department of Surgery, Klinikum rechts der Isar, Technische Universität München, Germany
| | - Valentin Becker
- 2nd Medical Department, Klinikum rechts der Isar, Technische Universität München, Germany
| | - Margit Bauer
- Department of Surgery, Klinikum rechts der Isar, Technische Universität München, Germany
| | - Michael Kranzfelder
- Department of Surgery, Klinikum rechts der Isar, Technische Universität München, Germany
| | - Rebekka Schirren
- Department of Surgery, Klinikum rechts der Isar, Technische Universität München, Germany
| | - Tim Lüth
- Institute of Microtechnology and Medical Device Technology, Klinikum rechts der Isar, Technische Universität München, Germany
| | - Alexander Meining
- 2nd Medical Department, Klinikum rechts der Isar, Technische Universität München, Germany
| | - Dirk Wilhelm
- Department of Surgery, Klinikum rechts der Isar, Technische Universität München, Germany
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Facilitating endoscopic submucosal dissection: the suture-pulley method significantly improves procedure time and minimizes technical difficulty compared with conventional technique: an ex vivo study (with video). Gastrointest Endosc 2014; 80:495-502. [PMID: 24679655 PMCID: PMC4426966 DOI: 10.1016/j.gie.2014.01.050] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2013] [Accepted: 01/29/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND The lack of countertraction in endoscopic submucosal dissection (ESD) results in increased technical demand and procedure time. Although the suture-pulley method for countertraction has been reported, its effectiveness compared with the traditional ESD technique remains unclear. OBJECTIVE To objectively analyze efficacy of countertraction using the suture-pulley method for ESD. DESIGN Prospective ex vivo animal study. SETTING Animal laboratory. INTERVENTIONS Twenty simulated gastric lesions were created in porcine stomachs by using a standard circular template 30 mm in diameter. In the control arm (n = 10), ESD was performed by using the standard technique. In the suture-pulley arm (N = 10), a circumferential incision was made, and an endoscopic suturing device was used to place the suture pulley. MAIN OUTCOME MEASUREMENTS The primary outcome of this study was total procedure time. RESULTS The median total procedure time with the suture-pulley method was significantly shorter than the traditional ESD technique (median, 25% to 75%, interquartile range [IQR]: 531 seconds [474.3-549.3 seconds] vs 845 seconds [656.3-1547.5 seconds], P < .001). The median time (IQR) for suture-pulley placement was 160.5 seconds (150.0-168.8 seconds). Although there was a significantly longer procedure time for proximal versus middle/lower stomach lesions with traditional ESD (median, 1601 seconds; IQR, 1547.5-1708.8 seconds vs median, 663 seconds; IQR, 627.5-681.8 seconds; P = .01), there was no significant difference in procedure time for lesions of various locations when using the suture-pulley method. Compared with traditional ESD, the suture-pulley method was less demanding in all categories evaluated by the NASA Task Load Index. LIMITATIONS Ex vivo study. CONCLUSIONS The suture-pulley method facilitates direct visualization of the submucosal layer during ESD and significantly reduces procedure time and technical difficulty. In addition, the benefit of the suture-pulley method was seen for both simple and more complicated ESDs.
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Raju GS. Endoscopic clip closure of gastrointestinal perforations, fistulae, and leaks. Dig Endosc 2014; 26 Suppl 1:95-104. [PMID: 24373001 DOI: 10.1111/den.12191] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 09/17/2013] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Gottumukkala S Raju
- Department of Gastroenterology, Hepatology, and Nutrition, University of Texas MD Anderson Cancer Center, Houston, USA
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Abstract
Esophageal leak is a life-threatening problem that can result from spontaneous rupture of the esophagus, cancer, anastomotic dehiscence after surgery, or as a complication of endoscopy. During the last decade, developments in the minimally invasive endoluminal approach to the management of esophageal leaks include utilization of endoscopy not only for diagnosis but also for closure of leaks with clips or sutures, bypass of the leaks with stents, and/or endoluminal drainage of mediastinal infection. The aim of this review is to summarize recent advances and the principles of endoscopic management of acute esophageal perforations.
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Affiliation(s)
- Rene Gomez-Esquivel
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1466, Houston, TX 77030, USA
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Fritscher-Ravens A, Milla P, Ellrichmann M, Hellwig I, Böttner M, Hadeler KG, Wedel T. A novel endoscopic prototype device for gastric full-thickness biopsy for the histopathologic diagnosis of GI neuromuscular pathology: in vivo porcine long-term survival study (with videos). Gastrointest Endosc 2013. [PMID: 23199648 DOI: 10.1016/j.gie.2012.09.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Many GI motility disorders are associated with underlying GI neuromuscular pathology, which requires full-thickness biopsies (FTB) for histopathologic diagnosis. Currently, none of the endoscopy-based attempts to obtain FTB specimens have proven suitable for routine use. This study evaluated a novel endoscopic prototype device (ED) for this purpose. OBJECTIVE To determine (1) the ability of the ED to obtain suitable FTB specimens, (2) associated complications, (3) feasibility of reliable defect closure, and (4) ability to evaluate intramural neuromuscular components. DESIGN Preclinical proof-of-concept study in 30 pigs. SETTING Animal laboratory. INTERVENTION Gastric FTB specimens were obtained with a circular cutter and anchor. The defect was closed by over-the-scope clips/T-tags. The resection site was inspected via laparoscopy. After 2 to 4 weeks, necropsy was carried out to evaluate late complications. MAIN OUTCOME MEASUREMENTS Feasibility, safety, and closure rate of the procedure. FTB specimens were assessed by histology/immunohistochemistry to visualize enteric neuromusculature. RESULTS A total of 29 of 30 procedures were successfully performed; one hemorrhage required endoscopic treatment. A total of 29 of 30 FTB specimens (mean diameter 9.1 mm) were retrieved in 7.1 ± 0.4 minutes (range 3.0-12.5 minutes), displaying optimal tissue quality. Defect closure took 10.8 ± 0.9 minutes (range 7.2-32 minutes). Laparoscopy did not reveal damage to adjacent organs. Necropsy showed well-healed scars at the resection site and no complications, peritonitis, or abscess formation. Histology showed smooth muscle layers and submucosal and myenteric ganglia. LIMITATIONS Survival animal pilot study, no patients. CONCLUSION The novel ED enabled safe harvesting of well-preserved FTB specimens. Defect closure proved to be reliable. All neuromuscular structures relevant for histopathologic evaluation of GI neuromuscular pathology were demonstrated. Further studies are needed to verify the efficacy of this prototype device in the entire gut and in humans.
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Affiliation(s)
- Annette Fritscher-Ravens
- Experimental Endoscopy, Internal Medicine I, University Hospital Schleswig-Holstein, Campus Kiel, Germany.
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Endoscopic vacuum therapy of anastomotic leakage and iatrogenic perforation in the esophagus. Surg Endosc 2012; 27:2040-5. [PMID: 23247743 DOI: 10.1007/s00464-012-2707-4] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2012] [Accepted: 11/06/2012] [Indexed: 12/17/2022]
Abstract
BACKGROUND The management of anastomotic leakage and iatrogenic esophageal perforation has shifted over recent decades from aggressive surgery to conservative and, recently, endoscopic therapy alternatives. The authors present their results for endoscopic vacuum therapy used to treat both entities. METHODS In the authors' institution, 17 cases of anastomotic leakage and 7 cases of iatrogenic perforation due to interventional endoscopy or rigid panendoscopy with either intraluminal or intracavitary endoscopic vacuum therapy were treated. RESULTS In 23 of 24 cases, the endoscopic treatment was successful. The median duration of therapy was 11 days (range, 4-46 days). All 7 cases of iatrogenic perforation and 16 of 17 anastomotic leakage cases were cured after a median therapy duration of 5 and 12 days, respectively. CONCLUSIONS Endoscopic vacuum therapy is applicable for a wide range of esophageal defects. In the authors' experience, it has seemed to be the best choice for iatrogenic perforations and has been a potent supplement in the management of anastomotic leakages.
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Natural orifice transesophageal endoscopic surgery: state of the art. Minim Invasive Surg 2012; 2012:896952. [PMID: 22567228 PMCID: PMC3337494 DOI: 10.1155/2012/896952] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2011] [Accepted: 02/09/2012] [Indexed: 12/21/2022] Open
Abstract
The main goal of Natural Orifice Transluminal Endoscopic Surgery (NOTES) is performing surgery avoiding skin incisions. Theoretical advantages of NOTES include decreased postoperative pain, reduction/elimination of general anesthesia, improved cosmetic outcomes, elimination of skin incision-related complications such as wound infections and hernias, and increased overall patient satisfaction. Although various forms of port creation to accomplish thoracic NOTES procedures have been proposed, transesophageal NOTES has been shown to be the most reliable one. The evolution of endoscopic submucosal transesophageal access resulted in the development of per-oral endoscopic myotomy (POEM), which had a fast transition to clinical practice. The authors present a review of the current state of the art concerning transesophageal NOTES, looking at its potential for diagnostic and therapeutic interventions as well as the hurdles yet to be overcome.
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Abstract
PURPOSE OF REVIEW Understanding the role of endoscopic closure techniques helps in expanding the endoscopist's role in the management of gastrointestinal neoplasia and explore new frontiers of minimally invasive endoluminal surgery. RECENT FINDINGS This article covers recent advances in endoscopic closure of various gastrointestinal perforations, with a special focus on devices, experimental evidence and clinical outcomes of endoscopic closure of gastrointestinal perforations. SUMMARY Endoscopic closure techniques help the endoscopist to walk on thin ice and save himself and the patient in the case of mishap.
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