Tulip bundle technique and fibrin glue injection: Unusual treatment of colonic perforation

Tulip-bundle technique for suture dehiscence in a Boerhaave syndrome

A 55-year-old-woman was admitted to the emergency department with hematemesis and abdominal pain. Her physical examination was unremarkable. Laboratory results without anemia. The upper gastrointestinal endoscopy revealed a deep large tear between 36 and 39 cm with transmural perforation. A diagnosis of Boerhaave syndrome was made. Thoraco-abdominal CT-scan revealed a laceration in the left posterolateral side of the esophagus, measuring 6.5 cm proximal to the esophagogastric junction (GEJ), associated with a pneumomediastinum, pneumoperitoneum and a mediastinal air fluid collection anteriorly to the GEJ. The patient was submitted to laparoscopic surgery with closure of the perforation, Graham patch confection. Nine days after, the esophago-gastric transit showed luminal contrast leakage to the posterior mediastinum. An endoscopic evaluation showed a 2 cm suture dehiscence. We applied a hemostatic clip in the distal end of the tear to bring the edges closer, but it was impossible to put additional ones. It was decided to perform a tulip-bundle technique with a single-channel endoscope in a sequential two-step maneuver and another two clips were placed in the borders of the tear with an endoloop applied over the clips with success. One month later, an endoscopic revaluation was performed, revealing the clips involved by the endoloop and no signs of leakage. After that, she started oral diet without any complications.

Colonoscopic perforations: Single center experience and review of the literature

OBJECTIVE

Iatrogenic colonic perforation is a well-known complication that can increase mortality and morbidity in patients undergoing colonoscopy. Closer follow-up and a well-planned treatment strategy are required when perforation arises as a complication. The aims of this study are to (1) report our experience with a large colonoscopy series; (2) evaluate the underlying mechanisms of iatrogenic colonic perforation; (3) discuss the ideal period between onset and treatment; and (4) review the current literature regarding the management of iatrogenic colonic perforations.

MATERIAL AND METHODS

Patients who underwent colonoscopy between January 2005 and May 2015 at a single center were reviewed retrospectively. Procedures during which colonic perforations occurred were documented and analyzed.

RESULTS

Between January 2005 and May 2015, 31,655 patients underwent colonoscopy and 5,214 patients underwent recto-sigmoidoscopy at our center. Thirteen of these procedures were associated with perforation. The perforation rate was found to be 0.041%. The most frequent locations of perforation were (a) the rectosigmoid junction, (b) the proximal rectum, and (c) the sigmoid colon. Management included surgical treatment in 11 patients and conservative management in 2 patients. Twelve patients (92.31%) were discharged uneventfully, and death occurred in one (7.69%) patient.

CONCLUSION

Although they are rarely encountered, colonic perforations are serious complications of colonoscopy. A high index of clinical suspicion is required for early diagnosis and appropriate treatment. Age, co-morbidities, the location and size of the perforation, and the time interval between onset and diagnosis should be evaluated, and the treatment approach should be planned accordingly.

Management of iatrogenic colorectal perforation: From surgery to endoscopy

Iatrogenic colon perforation is one the most pernicious complications for patients undergoing endoscopic screening or therapy. It is a serious but rare complication of colonoscopy. However, with the expansion of the indications for endoscopic therapies for gastrointestinal diseases, the frequency of colorectal perforation has increased. The management of iatrogenic colorectal perforation is still a challenge for many endoscopists. The methods for treating this complication vary, including conservative treatment, surgical treatment, laparoscopy and endoscopy. In this review, we highlight the etiology, recognition and treatment of colorectal iatrogenic perforation. Specifically, we shed light on the endoscopic management of this rare complication.

Management of duodenal stump fistula after gastrectomy for gastric cancer: Systematic review

AIM: To identify the most effective treatment of duodenal stump fistula (DSF) after gastrectomy for gastric cancer.

METHODS: A systematic review of the literature was performed. PubMed, EMBASE, Cochrane Library, CILEA Archive, BMJ Clinical Evidence and UpToDate databases were analyzed. Three hundred eighty-eight manuscripts were retrieved and analyzed and thirteen studies published between 1988 and 2014 were finally selected according to the inclusion criteria, for a total of 145 cases of DSF, which represented our group of study. Only patients with DSF after gastrectomy for malignancy were selected. Data about patients’ characteristics, type of treatment, short and long-term outcomes were extracted and analyzed.

RESULTS: In the 13 studies different types of treatment were proposed: conservative approach, surgical approach, percutaneous approach and endoscopic approach (3 cases). The overall mortality rate was 11.7% for the entire cohort. The more frequent complications were sepsis, abscesses, peritonitis, bleeding, pneumonia and multi-organ failure. Conservative approach was performed in 6 studies for a total of 79 patients, in patients with stable general condition, often associated with percutaneous approach. A complete resolution of the leakage was achieved in 92.3% of these patients, with a healing time ranging from 17 to 71 d. Surgical approach included duodenostomy, duodeno-jejunostomy, pancreatoduodenectomy and the use of rectus muscle flap. In-hospital stay of patients who underwent relaparotomy ranged from 1 to 1035 d. The percutaneous approach included drainage of abscesses or duodenostomy (32 cases) and percutaneous biliary diversion (13 cases). The median healing time in this group was 43 d.

CONCLUSION: Conservative approach is the treatment of choice, eventually associated with percutaneus drainage. Surgical approach should be reserved for severe cases or when conservative approaches fail.

Colonic perforation: can we manage it endoscopically?

Colonic perforation occurs in a variety of clinical scenarios and colonoscopy-associated perforation is one of the important reasons for colonic perforation. Colonoscopy-associated perforation may be diagnosed during colonoscopy procedure by the visualization of evident colonic wall defect or, after the completion of colonoscopy, by the visualization of leaked air in the peritoneal or retroperitoneal space. Recently, the incidence of colonoscopy-associated perforation increased because of the introduction of colorectal endoscopic submucosal dissection. Traditionally, colonoscopy-associated perforation was managed surgically. However, medical management has been introduced widely and endoscopic clipping is the most important component for the medical management of colonoscopy-associated perforation. Timely administration of antibiotics is also important. Large perforations, diagnostic colonoscopy-associated perforations, large amount of pneumoperitoneum, and severe abdominal pain have been reported to be predictive of the necessity of surgery after endoscopic clipping. Surgery should be performed if patients show clinical deterioration even after the initiation of medical management.