Endoscopic closure of GI fistulae by using an over-the-scope clip (with videos)

Endoscopic clip closure of gastrointestinal perforations, fistulae, and leaks

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.

Endoscopic closure of postoperative gastrointestinal leakages and fistulas with the Over-the-Scope Clip (OTSC)

BACKGROUND

In contrast to conventional Through-the-Scope Clips, the novel Over-the-Scope Clip (OTSC(®)) allows endoscopic full thickness closure of gastrointestinal leakages. The purpose of this study was to evaluate the efficacy and safety of the OTSC for the management of postoperative gastrointestinal leakages and fistulas.

METHODS

We retrospectively reviewed a series of 14 consecutive patients with postoperative gastrointestinal leakages and fistulas who were treated by OTSC application.

RESULTS

Nine OTSCs were used for upper GI tract leakages; five were used for colorectal leakages. Seventy-nine percent (11/14) of leakages were chronic (treated by OTSC later than postoperative day 14). In nine patients, other therapies preceded OTSC application. Median follow-up time was 5.5 months (range, 0.25-17). Primary technical success was achieved in all (14/14) patients. No adverse events related to the use of the OTSC device were noted. Three early recurrences were observed (two colonic fistulas, one esophageal anastomotic leakage), leading to a long-term success rate of 79 % (11/14). Leakage closure finally was achieved in these three patients by surgery or endoscopic vacuum therapy.

CONCLUSIONS

The OTSC system is an effective and safe method for the management of postoperative leakages and fistulas of the gastrointestinal tract. Its exact place in treatment algorithms of postoperative leakages will have to be determined.

Efficacy and safety of over-the-scope clip: Including complications after endoscopic submucosal dissection

AIM: To retrospectively review the results of over-the-scope clip (OTSC) use in our hospital and to examine the feasibility of using the OTSC to treat perforations after endoscopic submucosal dissection (ESD).

METHODS: We enrolled 23 patients who presented with gastrointestinal (GI) bleeding, fistulae and perforations and were treated with OTSCs (Ovesco Endoscopy GmbH, Tuebingen, Germany) between November 2011 and September 2012. Maximum lesion size was defined as lesion diameter. The number of OTSCs to be used per patient was not decided until the lesion was completely closed. We used a twin grasper (Ovesco Endoscopy GmbH, Tuebingen, Germany) as a grasping device for all the patients. A 9 mm OTSC was chosen for use in the esophagus and colon, and a 10 mm device was used for the stomach, duodenum and rectum. The overall success rate and complications were evaluated, with a particular emphasis on patients who had undergone ESD due to adenocarcinoma. In technical successful cases we included not only complete closing by using OTSCs, but also partial closing where complete closure with OTSCs is almost difficult. In overall clinical successful cases we included only complete closing by using only OTSCs perfectly. All the OTSCs were placed by 2 experienced endoscopists. The sites closed after ESD included not only the perforation site but also all defective ulcers sites.

RESULTS: A total of 23 patients [mean age 77 years (range 64-98 years)] underwent OTSC placement during the study period. The indications for OTSC placement were GI bleeding (n = 9), perforation (n = 10), fistula (n = 4) and the prevention of post-ESD duodenal artificial ulcer perforation (n = 1). One patient had a perforation caused by a glycerin enema, after which a fistula formed. Lesion closure using the OTSC alone was successful in 19 out of 23 patients, and overall success rate was 82.6%. A large lesion size (greater than 20 mm) and a delayed diagnosis (more than 1 wk) were the major contributing factors for the overall unsuccessful clinical cases. The location of the unsuccessful lesion was in the stomach. The median operation time in the successful cases was 18 min, and the average observation time was 67 d. During the observation period, none of the patients experienced any complications associated with OTSC placement. In addition, we successfully used the OTSC to close the perforation site after ESD in 6 patients. This was a single-center, retrospective study with a small sample size.

CONCLUSION: The OTSC is effective for treating GI bleeding, fistulae as well as perforations, and the OTSC technique proofed effective treatment for perforation after ESD.

Endoscopic management of complications after gastrointestinal weight loss surgery

As more patients undergo bariatric surgery, gastroenterologists will increasingly encounter variant postsurgical anatomies and postoperative complications. We discuss the diagnosis and management of bleeding, ulcers, foreign bodies, stenoses, leaks, fistulas, pancreaticobiliary diseases, weight regain, and dilated outlets.

Crohn's duodeno-colonic fistula preoperatively closed using a detachable endoloop and hemoclips: a case report

Duodeno-colonic fistula is an enterocolonic fistula that occurs as a complication of Crohn's disease. Symptoms of duodeno-colonic fistula are similar to those of Crohn's disease, such as weight loss and diarrhea. The treatment of choice is surgery, although medical treatment may also be considered. However, surgery is recommended when all available medical therapies have been ineffective. In this case, we report a secondary duodeno-colonic fistula due to Crohn's disease that was temporarily managed by an endoscopic procedure with a detached endoloop and hemoclips as a bridging therapy to final surgical repair.

Combined endoscopic techniques for closure of a chronic post-surgical gastrocutaneous fistula: case report and review of the literature (with video)

Several techniques have been proposed to seal post-operative leaks endoscopicaly, however, chronic fibrosed fistulas remain a tenacious problem. We describe the success of a combination of minimally invasive peroral endoscopic techniques to seal and permanently close a chronic gastrocutaneous fistula complicating a laparoscopic gastric bypass, these techniques included: fistuloscopy, argon plasma coagulation, mucosal stripping and the novel over-the-scope clips.

Endoscopic therapy for postoperative leaks and fistulae

Endoscopic techniques for the treatment of postoperative fistulae and leaks are rapidly developing. Conventional surgical therapy for postsurgical leaks and fistulae is associated with significant morbidity and mortality. Novel endoscopic therapies have demonstrated safety, despite the inherent challenges of intervention in this patient population, and are steadily building evidence for efficacy relative to surgical management. The article examines endoscopic therapy for leaks and fistulae after esophageal, gastric, bariatric, colonic, and pancreaticobiliary surgery.

Endoscopic closure of gastrointestinal defects with an over-the-scope clip device. A case series and review of the literature

BACKGROUND

The over-the-scope clip (OTSC) is a novel endoscopic tool used in the non surgical treatment of gastrointestinal perforations, fistula, and anastomotic leaks.

AIMS

The aim of the present study was to evaluate the therapeutic efficacy of this new endoscopic device on anastomotic postsurgical leak and fistulas or GI perforation in a tertiary referral center.

PATIENTS AND METHODS

The study group consisted of nine patients (three female, six male, age: 22-65 years). The indications were anastomotic leak in five patients, fistula in three patients, and perforation in one patient. Atraumatic version of OTSCs with medium sized caps, twin graspers and anchor were used. All of the patients were treated with only one OTSC. None of the patients underwent additional endoscopic treatments.

RESULTS

The median size of the defects were 15 mm (range 5-20 mm). OTSC was favourable in five of nine patients (three with leak, and one with fistula and perforation, each). OTSC could not be deployed or partially closed the defect in the remaining four patients because of fibrosis at the edges of the defect. Excluding the case with perforation, the median time elapsed between the diagnosis and the placement of OTSC was 35 days (range: 20-80) in the successful group and 70 days (range: 38-94) in the unsuccessful group. There were no complications due to the OTSC application or the applicator cap.

CONCLUSIONS

OTSC is a safe and effective device for closure of perforations and leaks. However therapeutic efficacy is lower in cases with fistulas mainly due to associated fibrosis at the borders.

Attempted endoscopic closure of a pancreaticocolonic fistula with an over-the-scope clip

CONTEXT

Spontaneous development of fistulae is an uncommon complication of acute pancreatitis. Until recently, surgical management has been the standard of care. Endoscopic treatment has been described with hemoclips and glue.

CASE REPORT

We report a case of a gentleman with a history of recurrent episodes of acute pancreatitis who presented with symptoms correlating with the development of a pancreatic-colonic fistula. Closure of the fistula was attempted with an over-the-scope clip.

CONCLUSION

More evidence is needed to determine criteria for use of over-the-scope clip in closure of GI and pancreatic fistulae.

Description of a new, endoscopic technique to remove the over-the-scope-clip in an ex vivo porcine model (with video)

BACKGROUND

Various studies have demonstrated the usefulness of the over-the-scope-clip (OTSC) to treat perforations, anastomotic leaks, and fistulae. Endoscopic removal of the OTSC was previously described in a series of 3 patients by using the Nd:YAG laser.

OBJECTIVE

To evaluate a new endoscopic technique to remove the OTSC.

DESIGN

Prospective, single-arm, pilot study in an ex vivo porcine model.

INTERVENTIONS

Perforations were created by using a surgical scalpel and a blunt trocar. Then they were endoscopically closed with the OTSC. Next, the OTSC was removed under endoscopic control by inserting a 0.035-inch straight hydrophilic tip guidewire into the oval hole on the side of the OTSC jaw. Afterward, the OTSC clip was removed by pulling on the wire.

RESULTS

Fifteen perforations were closed: with the OTSC. In all of the cases, the endoscopic closure of the defects was feasible and effective. Successful visualization of the oval hole of the OTSC was possible in 12 cases (80%), and guidewire cannulation was possible in all of these 12 cases (100%). Advancement of the guidewire through the OTSC and then the lumen of the stomach was accomplished in 8 cases (53.3%). In all of the cases with successful cannulation of the orifice, removal of the OTSC was managed safely. The result was an overall success rate of 53.3% (8 of 15 cases).

LIMITATIONS

Ex vivo porcine model.

CONCLUSIONS

Guidewire removal is a new and feasible technique to remove the OTSC. Future studies should refine the technique to enhance visualization and cannulation of the oval hole of the OTSC.

The anal fistula claw: the OTSC clip for anal fistula closure

AIM

Surgical closure of high or complex anal fistulae is often a difficult challenge. A special Nitinol clip, the OTSC clip (Ovesco AG), was evaluated for fistula closure in a porcine model.

METHOD

A total of 20 fistulae were created in 10 animals by seton insertion. Four weeks after fistula induction the setons were removed: one internal fistula opening per animal was left untreated as control whereas the other opening was closed by the OTSC clip using a specially developed transanal clip applicator. The safety and technical feasibility of the clip application were tested. Another 4 weeks later, fistulae were macroscopically assessed for closure. For histological examination, the anorectum including the fistula tract was excised en bloc.

RESULTS

Four weeks after clip placement, all external and internal fistula openings were macroscopically closed. The clip application site presented with an increased scarring. Microscopically, 40% of residual tracts and a more intense chronic inflammation were seen in the untreated control fistulae. After clip placement, 10% of the fistulae persisted associated with a higher density of collagen fibres indicating a better fistula scarring and healing. No unexpected side-effects or complications caused by the clip were observed.

CONCLUSION

Fistula closure using the OTSC clip represents a promising sphincter-preserving minimally invasive procedure. This study demonstrated the safety and feasibility of the 'anal fistula claw' for fistula closure. In spite of limitations of the porcine model the results justify clinical applications and further investigations.

The race for mainstream gastrointestinal endoscopy: frontrunners

In recent years, gastrointestinal endoscopy has evolved and branched out from a primary naked-eye diagnostic technique to a multitude of sophisticated investigative and therapeutic procedures. While many of the new endoscopic techniques are currently too complex or expensive to make it to mainstream clinical practice, others are already bringing major progress to the management of digestive diseases. In this review we will discuss a selected group of the emerging techniques and technologies used to increase the diagnostic yield in the colon and small intestine, including Third Eye® Retroscopes®, colon capsule endoscopy, spiral enteroscopy and confocal laser endomicroscopy. We will also discuss over-the-scope clip devices, a relatively simple and inexpensive tool potentially capable of noninvasive closing intestinal perforations and allowing the removal of infiltrating tumors.

Rectal perforations and fistulae secondary to a glycerin enema: Closure by over-the-scope-clip

Rectal perforations due to glycerin enemas (GE) typically occur when the patient is in a seated or lordotic standing position. Once the perforation occurs and peritonitis results, death is usually inevitable. We describe two cases of rectal perforation and fistula caused by a GE. An 88-year-old woman presented with a large rectal perforation and a fistula just after receiving a GE. Her case was further complicated by an abscess in the right rectal wall. The second patient was a 78-year-old woman who suffered from a rectovesical fistula after a GE. In both cases, we performed direct endoscopic abscess lavage with a saline solution and closed the fistula using an over-the-scope-clip (OTSC) procedure. These procedures resulted in dramatic improvement in both patients. Direct endoscopic lavage and OTSC closure are very useful for pararectal abscess lavage and fistula closure, respectively, in elderly patients who are in poor general condition. Our two cases are the first reports of the successful endoscopic closure of fistulae using double OTSCs after endoscopic lavage of the debris and an abscess of the rectum secondary to a GE.

Performance of the OTSC System in the endoscopic closure of gastrointestinal fistulae--a meta-analysis

BACKGROUND

Conventional endoscopic treatment options for closure of gastrointestinal fistulae are impaired by several limitations and therefore yield high rates of recurrence. Aim of the study is the evaluation of the primary-technical and secondary-clinical success rates in closure of gastrointestinal fistulae by means of the OTSC System.

DESIGN/METHODS

The database Medline was systematically searched for primary research on the evaluation of the OTSC System in closure of gastrointestinal fistulae. Appraisal of studies for inclusion and data extraction were performed independently by two reviewers using an a priori determined data extraction grid.

RESULTS

A total of 19 primary research articles were identified. The examined studies comprised case reports as well as case series and clinical single-arm studies (n = 7) with a limited number of participants. Reviewed studies revealed a high rate of procedural success (mean 84.6%; 95% confidence interval 66.6 to 93.8%) and durable clinical success (mean 69.0%; 95% confidence interval 51.8 to 82.2%). Failed attempts and incomplete closures were mainly ascribed to the challenging effort of treating highly fibrotic chronic fistulae.

CONCLUSION

Endoscopic closure of gastrointestinal fistulae by means of the OTSC System is a safe and effective method.

The OTSC® Proctology clip system for anorectal fistula closure: the 'anal fistula claw': case report

Abstract Surgical treatment of high or complex anal fistulas often renders unsatisfying results. This is the report of the first successful closure of such anal fistula using a special Nitinol clip and applicator, the OTSC® Proctology system (Ovesco AG, Tuebingen, Germany): A 54-year old female patient was suffering from a high transsphincteric anal fistula. After seton drainage of the fistula for ten weeks, the fistula track was debrided using a special fistula brush. After transanal clip release from the applicator, the internal fistula opening was adequately closed by the clip. Eight months after clip closure the fistula had healed and the clip was removed using the OTSC® Proctology Clip Cutter. Fistula closure using the OTSC® Proctology system represents a promising sphincter-preserving minimally invasive procedure.

The over-the-scope clip system--a novel technique for gastrocutaneous fistula closure: the first North American experience. Can J Gastroenterol. 2012;26:193-195. [PMID: 22506258 DOI: 10.1155/2012/452340]

BACKGROUND

The mainstay of therapy for gastrocutaneous (GC) fistulas has been surgical intervention. However, endoclips are currently used for management of perforations and fistulas but are limited by their ability to entrap and hold the tissue.

OBJECTIVE

To report the first North American experience with a commercially available over-the-scope clip (OTSC) device, a novel and new tool for the endoscopic entrapment of tissue for the closure of fistula and perforations.

METHODS

The present single-centre study was conducted at a tertiary referral academic gastroenterology unit and centre for advanced therapeutic endoscopy and involved patients referred for endoscopic treatment for the closure of a GC fistula. The OTSC device was mounted on the tip of the endoscope and passed into the stomach to the level of the fistula. The targeted site of the fistula was grasped with the tissue anchoring tripod and pulled into the cap with concomitant scope channel suction. Once the tissue was trapped in the cap, a 'bear claw' clip was deployed.

RESULTS

The patients recovered with fistula closure. No complication or recurrence was noted. Fistula sizes >1 cm, however, were difficult to close with the OTSC system. The length of stay of the bear claw clip at the fistula site is unpredictable, which may lead to incomplete closure of the fistula.

CONCLUSION

Closure of a GC fistula using a novel 'bear claw' clip system is feasible and safe.

A new approach to gastrointestinal fistula closure: endoloop and clips technique using double endoscope

Several endoscopic techniques have been described for closure of gastrointestinal fistulas. Herein, we describe a case of iatrogenic gastric fistula successfully treated with a new approach by simultaneous insertion of two endoscopes and using the endoloop and endoclips technique.

Hemodynamic efficacy of the over-the-scope clip in an established porcine cadaveric model for spurting bleeding

BACKGROUND

Clip application has been proven to be effective for endoscopic hemostasis. There are limited bench data on the efficacy of the over-the-scope clip (OTSC) for the treatment of spurting GI hemorrhage. We evaluated the hemodynamic efficacy of the OTSC in an established bleeding model.

OBJECTIVE

To evaluate the hemodynamic efficacy of the OTSC in an established bleeding model.

DESIGN

Prospective experimental trial with historical comparison.

SETTING

We tested the OTSC prospectively in a validated bleeding model by using the compact Erlangen Active Simulator for Interventional Endoscopy equipped with an upper GI organ package. The artificial blood circulation system of the simulator was connected to an arterial pressure transducer. Two investigators with different endoscopic experience (4000 and 10,000 endoscopies performed) participated. Each investigator treated 16 bleeding sites in the simulator with the OTSC by using only suction (n = 8) and a novel retraction device to grasp tissue (n = 8). Systemic pressures were recorded 1 minute before, during, and 1 minute after clip application to objectify the effects of clipping on the vessel diameter.

MAIN OUTCOME MEASUREMENTS

Mean and maximum reduction in vessel diameter.

RESULTS

The application of the OTSC on the bleeding vessel led to a significant increase in systemic pressure (P < .001) and decreased vessel diameter (P < .001) independent of the endoscopic experience of the investigator. There was no difference in the decrease in vessel diameter based on the application technique (suction vs suction plus grasping). A historical comparison with our former trials demonstrated that the OTSC decreased the vessel diameter significantly more than other traditional endoclips.

LIMITATIONS

Small sample size.

CONCLUSIONS

We could demonstrate the efficacy of the OTSC with increased hemodynamic efficiency compared with other endoscopic clip devices tested previously.

Benefit of a clipping device in use in intestinal bleeding and intestinal leakage

BACKGROUND

The over-the-scope clip (OTSC) system was first used to close the access route in natural orifice transluminal endoscopic surgery and is increasingly used for other indications.

OBJECTIVE

We analyzed the use of the OTSC in intestinal bleeding and in closure of GI tract leaks.

DESIGN

Analysis of a consecutive series of patients.

SETTING

University hospital.

PATIENTS

Nineteen patients (group A: closure of GI leak site, n = 12; group B: complex GI bleeding, n = 7) were retrospectively enrolled in this study. We analyzed outcome and follow-up (6-68 weeks; group A: mean 37 weeks, standard deviation 24) in terms of treatment success (closure of the GI tract leak/durable hemostasis).

INTERVENTION

Endoscopic application of OTSCs.

MAIN OUTCOME MEASUREMENTS

Resolution of leaks, closure of fistula (group A), or stopping bleeding (group B).

RESULTS

In group A, durable closure was achieved in 8 of 12 patients. Sealing a postoperative/postinterventional leak was successful in 6 patients and failed in 3. A gastrocutaneous fistula was primarily closed successfully in 2 patients, but recurred in 1 of these patients. A gastric wall dehiscence in necrotizing pancreatitis was successfully closed in another patient. Group B patients had previous endoscopic treatment failure in 4 of 7 patients (through-the-scope clips, injection of Suprarenin or fibrin glue, others) and were deemed not treatable by through-the-scope clips in 3 of 7 patients. The primary success rate was 100% (7 of 7 patients); durable hemostasis was achieved in 4 of 7 patients, whereas surgery or angiography was necessary in the remaining patients.

LIMITATIONS

Retrospective analysis.

CONCLUSIONS

Leaks and fistulae are reliably closed with OTSCs in tissue flexible enough to be sucked into the attached cap (eg, in lesions caused <1 week before). GI bleeding may be stopped by OTSCs with reliable transient hemostasis, but durable hemostasis is less frequent.