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

Exposed endoscopic full-thickness resection and overstitch suture after incomplete nonexposed endoscopic full-thickness resection

Video 1Endoscopic resection and suture of neoplastic recurrence after the use of endoscopic full-thickness resection devices for invasive rectal adenocarcinoma.

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®.

Novel through-the-scope twin clip for the closure of GI wounds: the first experimental survival study in pigs (with videos)

BACKGROUND AND AIMS

We developed a through-the-scope twin clip (TTS-TC) for closing GI wounds. The objective of this study was to evaluate the efficacy and safety of the TTS-TC in GI wound closure.

METHODS

GI nonperforating and perforating wounds (≥2.5 cm) were created in live pigs. TTS-TCs were used to convert the large wounds into small wounds. The remaining small wounds were closed using conventional through-the-scope clips (TTSCs). The follow-up period was 1 month. Location and size of the wound, time of wound closure, intraoperative and postoperative adverse events, and conditions of wound healing were investigated.

RESULTS

Thirteen wounds were created in 5 live pigs, including 2 gastric nonperforating and 3 perforating wounds and 5 large intestinal nonperforating and 3 perforating wounds. The mean long and short diameters of the wounds were 4.1 (± .9) cm and 3.4 (± .7) cm, respectively. All wounds were successfully closed using the TTS-TCs combined with TTSCs. The total mean time for wound closure was 9.2 (± 5.3) minutes, and the mean time for using the TTS-TCs was 3.9 (± 4.7) minutes. During the 1-month follow-up period, no bleeding, perforation, or death occurred; all wounds healed with scar formation; and all TTS-TCs detached spontaneously.

CONCLUSIONS

The TTS-TC was successfully used to close large-sized GI wounds. The TTS-TC is a promising tool for large-size wound closure under flexible endoscopy.

A Comprehensive Review of Endoscopic Management of Sleeve Gastrectomy Leaks

BACKGROUND

Bariatric surgery leaks result in significant morbidity and mortality. Experts report variable therapeutic approaches, without uniform guidelines or consensus.

OBJECTIVE

To review the pathogenesis, risk factors, prevention, and treatment of gastric sleeve leaks, with a focus on endoscopic approaches. In addition, the efficacy and success rates of different treatment modalities are assessed.

DESIGN

A comprehensive review was conducted using a thorough literature search of 5 online electronic databases (PubMed, PubMed Central, Cochrane, EMBASE, and Web of Science) from the time of their inception through March 2020. Studies evaluating gastric sleeve leaks were included. MeSH terms related to "endoscopic," "leak," "sleeve," "gastrectomy," "anastomotic," and "bariatric" were applied to a highly sensitive search strategy. The main outcomes were epidemiology, pathophysiology, diagnosis, treatment, and outcomes.

RESULTS

Literature search yielded 2418 studies of which 438 were incorporated into the review. Shock and peritonitis necessitate early surgical intervention for leaks. Endoscopic therapies in acute and early leaks involve modalities with a focus on one of: (i) defect closure, (ii) wall diversion, or (iii) wall exclusion. Surgical revision is required if endoscopic therapies fail to control leaks after 6 months. Chronic leaks require one or more endoscopic, radiologic, or surgical approaches for fluid collection drainage to facilitate adequate healing. Success rates depend on provider and center expertise.

CONCLUSION

Endoscopic management of leaks post sleeve gastrectomy is a minimally invasive and effective alternative to surgery. Their effect may vary based on clinical presentation, timing or leak morphology, and should be tailored to the appropriate endoscopic modality of treatment.

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.

Fully Covered Self-Expandable Metal Stens eliminate surgical repair requirement in both endoscopic sphincterotomy and precut sphincterotomy-related perforation (with video)

OBJECTIVE

Endoscopic retrograde cholangiopancreatography (ERCP)-related perforations occur in 0.3-0.6% of patients. The treatment of retroperitoneal paravaterian perforations (type II), which develop during endoscopic sphincterotomy or precut sphincterotomy, remains a matter of debate. We aimed to evaluate the efficacy of fully covered self expandable metal stent (Fc-SEMS) placement in the treatment of type II perforations.

METHODS

The study was conducted in a tertiary ERCP reference center of Turkey between December 2013 and June 2016. Patients with type II ERCP-related perforation constituted the study group. Type II perforations were treated by insertion of an Fc-SEMS (10 mm × 60 mm) during the ERCP procedure or intraoperatively by surgery-endoscopy rendezvous technique, if biliary cannulation could not be achieved.

RESULTS

A total of 2689 ERCPs were performed. ERCP-related perforation was observed in 12 procedures (0.4%). Eight patients had Stapfer type II perforations, which developed during endoscopic sphincterotomy in seven patients and precut sphincterotomy in one patient. Fc-SEMSs were inserted during the ERCP procedure in seven patients and intraoperatively by surgery-endoscopy rendezvous technique in one patient. None of the patients developed fever, hemodynamic instability, or peritoneal signs. Stents were removed after a median duration of 9 (3-14) days. All of the patients were uneventfully discharged after an average hospital length of stay of median 5 (1-9) days.

CONCLUSION

Fc-SEMSs are highly effective in the nonoperative treatment of type II perforations and their intraoperative insertion in patients with unsuccessful cannulation may facilitate surgery by eliminating the need for duodenum repair surgery.

The Use of the Overstitch to Close Perforations and Fistulas

Endoscopic suturing allows for select patients with perforations, leaks, and fistulas to be managed endoscopically. Experience with the Overstitch endoscopic suturing device suggests it may be superior to endoclips in the management of perforations, because of its ability to achieve full-thickness suturing and create an airtight closure. Although successful closure of leaks and fistulas using the Overstitch device has been described, additional therapy with a multimodality approach is often required because of inherent challenges with fistula recurrence. This article reviews the existing literature on the Overstitch endoscopic suturing system specifically in the management of gastrointestinal perforations, leaks, and fistulas.

Endoscopic management of perforations, leaks and fistulas

The endoscopic management armamentarium of gastrointestinal disruptions including perforations, leaks, and fistulas has slowly but steadily broadened in recent years. Previously limited to surgical or conservative medical management, innovations in advanced endoscopic techniques like natural orifice transluminal endoscopic surgery (NOTES) have paved the path towards development of endoscopic closure techniques. Early recognition of a gastrointestinal defect is the most important independent variable in determining successful endoscopic closure and patient outcome. Some devices including through the scope clips and stents have been well studied for other indications and have produced encouraging results in closure of gastrointestinal perforations, leaks and fistulas. Over the scope clips, endoscopic sutures, vacuum therapy, glue, and cardiac device occluders are other alternative techniques that can be employed for successful endoscopic closure.

Endoscopic Full-Thickness Defects and Closure Techniques

PURPOSE OF REVIEW

Gastrointestinal transmural defects are defined as total rupture of the gastrointestinal wall and can be divided into three main categories: perforations, leaks, and fistulas. Due to an increase in the number of therapeutic endoscopic procedures including full-thickness resections and the increase incidence of complications related to bariatric surgeries, there has been an increase in the number of transmural defects seen in clinical practice and the number of non-invasive endoscopic treatment procedures used to treat these defects.

RECENT FINDINGS

The variety of endoscopic approaches and devices, including closure techniques using clips, endoloop, and endoscopic sutures; covering techniques such as the cardiac septal occluder device, luminal stents, and tissue sealants; and drainage techniques including endoscopic vacuum therapy, pigtail, and septotomy with balloon dilation are transforming endoscopy as the first-line approach for therapy of these conditions. In this review, we describe the various transmural defects and the endoscopic techniques and devices used in their closure.

Endoscopic Management of Transmural Defects, Including Leaks, Perforations, and Fistulae

Transmural defects of the gastrointestinal tract can be classified into 3 distinct entities-leak, perforation, and fistula. Each arises from different mechanisms and is managed accordingly. Leaks occur most often after surgery, while perforations occur most often after flexible endoscopic maneuvers. Fistulae arise from a variety of mechanisms, such as an evolution from surgical leaks, as well as from specific disease states. Endoscopic management plays a vital role in the treatment of transmural defects as long as the region of interest can be accessed with the appropriate endoscopic accessories. Endoscopic approaches can be broadly classified into those that provide closure and those that provide diversion of luminal contents. With advances in technology, a myriad of devices and accessories are available that allow a tailored approach. Endoscopic approaches to leaks, perforations, and fistulae are discussed in this review.

Can a Fully Covered Self-Expandable Metallic Stent be Used Temporarily for the Management of Duodenal Retroperitoneal Perforation During ERCP as a Part of Conservative Therapy?

PURPOSE

There are no reports comparing the results of conservative/nonsurgical management with the addition of fully covered self-expandable metallic stents (FCSEMS) with the conservative approach in endoscopic retrograde cholangiopancreatography (ERCP)-related duodenal retroperitoneal (type II) perforations. The aim of this study was to evaluate whether the addition of FCSEMS to conventional treatment provides further benefits in the course of type II perforations.

METHODS

A total of 7471 ERCP with sphincterotomy performed between 2007 and 2014 were evaluated, and a total of 25 type II perforations (0.33%) were identified. About 20 patients who were detected during ERCP and biliary cannulation was accomplished were included in the study. Patients were divided into 2 groups: the conservative treatment group (10 patients) and the FCSEMS group (10 patients). Groups were compared for clinical findings, results of serial white blood cell (WBC) counts, the length of hospital stay, the need for surgery, and death, retrospectively.

RESULTS

Five patients in the conservative treatment group and none of the patients in the FCSEMS group had pain requiring narcotic and/or nonsteroidal anti-inflammatory analgesics during the follow-up period (P=0.005). On post-ERCP day 1, in the conservative and the FCSEMS groups, mean WBC counts were 13,218±4410×10 and 8714±3270×10, respectively (P=0.029). The perforation-related length of hospital stay was 15.77±5.21 days in the conservative group and 11.7±3.19 days in the FCSEMS group (P=0.053). Excluding the patient with severe pancreatitis in the conservative group, there were no deaths or need for surgery.

CONCLUSIONS

Compared with conservative treatment alone, the addition of FCSEMS provides further benefits in terms of a painless course, lower WBC counts, and a short hospital stay. FCSEMS can be used as an additional treatment modality in type II perforation.

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.