Endoscopic Management with a Novel Over-The-Scope Padlock Clip System

Advancements in endoscopic hemostasis for non-variceal upper gastrointestinal bleeding

Non-variceal upper gastrointestinal (GI) bleeding is a significant cause of morbidity and mortality. Traditionally, through-the-scope (TTS) clips, thermal therapy, and injection therapies are used to treat GI bleeding. In this review, we provide an overview of novel endoscopic treatments that can be used to achieve hemostasis. Specifically, we discuss the efficacy and applicability of over-the-scope clips, hemostatic agents, TTS doppler ultrasound, and endoscopic ultrasound, each of which offer an effective method of reducing rates of GI rebleeding.

Updates on the Prevention and Management of Post-Polypectomy Bleeding in the Colon

Post-polypectomy bleeding (PPB) remains a significant procedure-related complication, with multiple risk factors determining the risk including patient demographics, polyp characteristics, endoscopist expertise, and techniques of polypectomy. Immediate PPB is usually treated promptly, but management of delayed PPB can be challenging. Cold snare polypectomy is the optimal technique for small sessile polyps with hot snare polypectomy for pedunculated and large sessile polyps. Topical hemostatic powders and gels are being investigated for the prevention and management of PPB. Further studies are needed to compare these topical agents with conventional therapy.

Usage of Padlock Over-the-Scope-Clip in Difficult-to-Control Recurrent Gastrointestinal Bleeding Due to a Gastric Dieulafoy Lesion

Dieulafoy's lesions (DLs) are a rare cause of acute gastrointestinal bleeds (GIBs). Here we describe Over-the-Scope Clip Padlock System (OTSC-P) use to treat a gastric fundus DL with recurrent bleeding despite other interventions. The OTSC-P was created for full-thickness defect closure in the event of a perforation, but use has expanded to treatment of GIB. They consist of metal clips mounted on transparent caps, delivered via endoscope. Their size allows control of larger bleeding lesions, provides enhanced tissue stability and the firmer clip grasp reduces rebleeding or clip dislodgement.

Colonic diverticular bleeding: An update on pathogenesis and management

Colonic diverticular bleeding is the most common cause of lower gastrointestinal (GI) bleeding, which can be life-threatening and frequently recurrent. In recent years, the prevalence of diverticulosis has increased in developed countries, with a documented incidence of 50% in patients older than 60 years. Based on the evidence, the use of anticoagulants and/or antiplatelets in the elderly population has resulted in an increased incidence of acute diverticular bleeding. According to the literature, about 50% of patients with diverticular bleeding require a blood transfusion, and 18% - 53% need emergency surgery. Although endoscopic identification of the culprit diverticula and appropriate intervention is a challenge, the newer treatment modality, over-the-scope clip method (OTSC) has been demonstrated to be an effective endoscopic hemostatic method in severe diverticular bleeding, especially in cases of rebleeding after first-line conventional endoscopic procedures. In this review, we summarize the pathophysiology of colonic diverticulosis and diverticular bleeding, recent evidence in its management, and existing theories on various preventive strategies to control diverticular bleeding. We also discuss the efficacy and treatment outcome of the OTSC technique in controlling diverticular bleeding.

The application of endoscopic loop ligation in defect repair following endoscopic full-thickness resection of gastric submucosal tumors originating from the muscularis propria layer

OBJECTIVE

We sought to investigate the clinical efficacy and safety of a novel endoscopic closure technique in repairing gastric wall defects after endoscopic full-thickness resection (EFTR) of gastric submucosal tumors (SMTs) originating from the muscularis propria layer.

METHODS

From December 2016 to December 2019, patients with gastric submucosal tumors were enrolled and clinicopathological data were collected. All SMTs were resected by EFTR and gastric wall defects were closed using a novel endoscopic closure technique. The feasibility, efficacy, and safety were evaluated.

RESULTS

A total of 21 patients with gastric SMTs were included in this study. Among the included SMTs, 15 tumors were located in the fundus of the stomach, and 6 were located in the upper body of the stomach. The average size of the lesions was 2.3 cm (range: 1.9-2.5 cm). All patients underwent EFTR and the gastric wall defect was closed by endoscopic closure. The average endoscopic closure time was 9 min (range: 7-15 min) and the average hospitalization stay length was five days (range: 4-6 days). One patient developed abdominal pain on the first day after the procedure and their body temperature increased; he received treatments such as anti-infection, antacid, and gastrointestinal decompression and was cured and discharged after 4 days. No instance of delayed bleeding, postoperative gastrointestinal fistula, or abdominal infection occurred. No case was transferred to surgery. The postoperative pathology profile included 18 stromal tumors and 3 leiomyomas. During the follow-up period (6-24 months), no case of residual or recurrence was recorded.

CONCLUSION

The described endoscopic loop ligation technique is feasible, effective, and safe for repairing gastric wall defects after EFTR for gastric submucosal tumors originating from the muscularis propria layer.

Editors' Choice of Noteworthy Clinical Endoscopy Publications in the First Decade

This is a special review to celebrate the 10^th anniversary of Clinical Endoscopy. Each deputy editor has selected articles from one’s subspecialty that are significant in terms of the number of downloads, citations, and clinical importance. The articles included original articles, review articles, systematic reviews, and meta-analyses.

Successful Endoscopic Removal of Toothpick Perforating Gastric Antrum With Over-the-Scope Padlock Clip Closure

Our unique case demonstrates the use of an over-the-scope Padlock clip for closure of a sharp foreign body induced gastric perforation, avoiding the need for surgical intervention. A 47-year old female presented with a two-day history of abdominal pain with nausea. Abdominal CT scan revealed a linear density in the distal body of the stomach extending outside the lumen. Endoscopic evaluation revealed a toothpick perforating through the wall of the gastric antrum. Endoscopic removal was performed, and closure of the full-thickness defect was achieved with an over-the-scope Padlock clip. The patient subsequently made an uneventful recovery, with no reported complications at two-year follow-up. Early endoscopic removal and closure of gastric luminal perforations by over-the-scope Padlock clips are viable alternative treatments for defects previously considered only amenable to surgical repair. Endoscopic treatment of gastrointestinal perforations has shown to decrease the morbidity and mortality associated with more invasive surgical procedures.

Another Use for Padlock Clip

The novel over-the-scope Padlock clip was reported to assist in the management of esophageal fistulas, refractory gastrointestinal (GI) bleeding, and GI defects closure. A little is known about the management of non-lifting colon polyps with fibrosis secondary to prior intervention. Resection could be challenging given prior intervention. The tools used to remove such polyps are different between institutions.

In this study, we describe our experience with Padlock clip in removing non-lifting colon polyp.

Mucosectomy device-assisted endoscopic resection of gastric subepithelial lesions

OBJECTIVE

Some gastrointestinal subepithelial tumors (SETs) have malignant potential and complete resection may be required. However, endoscopic submucosal dissection (ESD) can be a tedious procedure and requires a long and extensive training to master. Devices for endoscopic full-thickness resection (EFTR) are limited and are not widely available. We report here a simpler endoscopic method to resect small SETs using a commercially available endoscopic mucosal resection (EMR) kit and enucleation technique.

METHODS

All patients with SET who underwent device-assisted resection at our tertiary care hospital from April 2015 to November 2016 were enrolled in this retrospective study. All procedures were performed by a single expert endoscopist with an advanced endoscopy trainee. A mucosectomy and a limited dissection under mucosa were performed to preserve the mucosa before a device-assisted enucleation of the tumor to facilitate endoscopic closure of the defect closure in all cases.

RESULTS

A total of 12 patients aged 38-70 y, of whom six were males, were included. Most of the tumors originated from the muscularis propria and were located at the proximal gastric body. The mean procedural duration was 53 minutes (range 23-91 min). The average size of the lesions was 13 mm (range 9-21 mm). The mean duration of hospitalization was 1.3 days. Bleeding and intentional perforation were all successfully managed during the procedure and did not result in any clinically significant adverse event.

CONCLUSION

A device-assisted EFTR using a commercially available EMR kit is a safe and feasible method for the endoscopic resection of small gastric extrovert SETs.