Our experience with endoscopic repair of large colonoscopic perforations and review of the literature

Zipper repair of 3 cm iatrogenic colonic perforation with dual-channel endoscope and twin grasper-assisted titanium clip

A 53-year-old man undergoing painless colonoscopy for long-term diarrhea. After colonoscopy withdrawing to the sigmoid colon, a local perforation was found, about 3 cm in size, oval in shape. We used a two-channel endoscope and grip to pull the edges of the intestinal wall on both sides of the perforation site to close together, and then repair the 3 cm oval perforation of the colon through multiple ordinary titanium clips. The patient had no obvious infection after surgery and recovered well after 1 month of follow-up. Preliminary experience has shown that using multiple titanium clips under dual-channel endoscope to zipper suture can effectively repair 3 cm iatrogenic colonic perforations.

Laparoscopic management of colovesical fistula in different clinical scenarios

INTRODUCTION

Colovesical fistula (CVF) is a condition with various aetiologies and presentations. Surgical treatment is necessary in most cases. Due to its complexity, open approach is preferred. However, laparoscopic approach is reported in the management of CVF due to diverticular disease. The aim of this study was to analyse the management and outcome of patients with CVF of different aetiologies treated with laparoscopic approach.

PATIENTS AND METHODS

This was a retrospective study. We retrospectively reviewed all patients undergoing elective laparoscopic management of CVF from March 2015 to December 2019.

STATISTICAL ANALYSIS USED

None.

RESULTS

Nine patients underwent laparoscopic management of CVF. There were no intraoperative complications or conversions to open surgery. A sigmoidectomy was performed in eight cases. In one patient, a fistulectomy with sigmoid and bladder defect closure was performed. In two cases of locally advanced colorectal cancer with bladder invasion, a multi-stage procedure with temporary colostomy was chosen. In three cases, with no intraoperative leakage, we did not perform bladder suture. Four Clavien I-II complications were recorded. Two fragile patients died in the post-operative period. No patients required re-operation. At a median follow-up of 21 months (interquartile range: 6-47), none of the patients had recurrence of fistula.

CONCLUSIONS

CVF can be managed with laparoscopic approach by skilled laparoscopic surgeons in different clinical scenarios. Bladder suture is not necessary if leakage is absent. Informed counselling to the patient must be guaranteed concerning the risk of major complications and mortality in case of CVF due to malignant disease.

Iatrogenic colon perforation during colonoscopy, diagnosis/treatment, and follow-up processes: A single-center experience

Objectives

latrogenic colon perforation (ICP) is one of the most feared complications of colonoscopy and causes unwanted morbidity and mortality. In this study, we aimed to discuss the characteristics of the cases of ICP we encountered in our endoscopy clinic, its etiology, our treatment approaches, and results in the light of the current literature.

Material and Methods

We retrospectively evaluated the cases of ICP among 9.709 lower gastrointestinal system endoscopy procedures (colonoscopy + rectosigmoidoscopy) performed for diagnostic purposes in our endoscopy clinic during 2002-2020.

Results

A total of seven cases of ICP were detected. The diagnosis was made during the procedure in six patients and after eight hours in one patient, and their treatment was performed urgently. Whereas surgical procedures were performed in all patients, the type of the procedure varied; laparoscopic primary repair was performed in two patients and laparotomy in five patients. In the patients who underwent laparotomy, primary repair was performed in three patients, partial colon resection and end-to-end anastomosis in one patient, and loop colostomy in one patient. The patients were hospitalized for an average of 7.14 days. The patients who did not develop complications in the postoperative follow-up were discharged with full recovery.

Conclusion

Prompt diagnosis and appropriate treatment of ICP is crucial to prevent morbidity and mortality.

Case Report: Abdominal Cocoon With Jejuno-Ileo-Colonic Fistula

Introduction

Abdominal cocoon is a unique peritoneal disease that is frequently misdiagnosed. The occurrence of the abdominal cocoon with a jejuno-ileo-colonic fistula has not been previously reported.

Case Presentation

We admitted a 41-year-old female patient with an abdominal cocoon and a jejuno-ileo-colonic fistula. She was admitted to our hospital for the following reasons: “the menstrual cycle is prolonged for half a year, and fatigue, palpitations, and shortness of breath for 2 months”. On the morning of the 4th day of admission, the patient experienced sudden, severe, and intolerable abdominal pain after defecating. An emergency abdominal CT examination revealed intestinal obstruction. Surgery was performed, and the small intestine and colon were observed to be conglutinated and twisted into a mass surrounded by a fibrous membrane, and an enteroenteric fistula was observed between the jejunum, ileum, and sigmoid colon. We successfully relieved the intestinal obstruction and performed adhesiolysis. The patient was discharged from our hospital on the 6th postoperative day, then she recovered and was discharged from Feicheng People's Hospital after another 11 days of conservative treatment, and she recovered well-during the 2-month follow-up period.

Conclusion

Abdominal cocoon coexisting with a jejuno-ileo-colonic fistula is very rare. During the process of abdominal cocoon treatment, the patient's medical history should be understood in detail before the operation, and the abdominal organs should be carefully evaluated during the operation to avoid missed diagnoses.

Closure of colonic deep mural injury and perforation with endoclips

INTRODUCTION

colorectal perforations are one of the most feared complications after performing an endoscopic resection. The use of endoclips is considered for the management of these complications.

OBJECTIVES

to evaluate the efficacy and safety of the use of endoclips in the management of perforations and deep mural injuries that occur after an endoscopic colorectal resection.

METHODS

a prospective cohort of consecutively included patients was used with a diagnosis of perforation or deep mural injury after an endoscopic colorectal resection treated with endoclips in our institution. The rates of perforation and deep mural injury were obtained. The factors associated with an unfavorable evolution after the placement of the endoclips were analyzed.

RESULTS

after 342 endoscopic mucosal resections (EMR) and 42 endoscopic submucosal dissections (ESD), there were 25 cases with perforation or deep mural injury. The deep mural injury rate was 3.22 % and 7.14 % in the case of EMR and ESD, respectively. The perforation rate was 1.46 % and 14.29 % in the case of EMR and ESD, respectively. Successful closure with endoclips was achieved in 24 cases (96 %). Only one patient presented an unfavorable evolution (10 %) after successful closure. The factors associated with an unfavorable evolution were the presence of diffuse peritoneal symptoms and a perforation size greater than or equal to 10 mm.

CONCLUSION

endoscopic closure with endoclips is effective to avoid surgery in cases of deep mural injury or perforation after an endoscopic resection.

A Case of Tension Pneumothorax After Diverticular Rupture During Diagnostic Colonoscopy

Colonoscopy is routinely used for the diagnosis and treatment of colorectal diseases. Bowel perforation is a rare but severe complication that significantly increases the morbidity and mortality. Tension pneumothorax is an uncommon complication of colonic perforation. We present a case of the successful treatment of a patient with tension pneumothorax, following colonoscopy, by using tube thoracostomy and Hartman-type resection of the rectosigmoid junction and proximal sigmoid. Surgeons, anesthesiologists, and endoscopists should consider the possibility of pneumothorax as a rare complication of colonoscopy. Early detection and urgent treatment is the key to successful management.

Clinical Characteristics of Colonoscopic Perforation and Risk Factors for Complications After Surgical Treatment

Background: There are few studies on postoperative complications after colonoscopic perforation. We aimed to study clinical characteristics and treatment after colonoscopic perforation, and to determine risk factors for postoperative complications by surgical treatment of colonoscopy perforation. Methods: Cases with perforation within 7 days after colonoscopy from January 2017 to December 2019 were collected for retrospective analysis. Data regarding demography, clinical information, colonoscopy, perforation, and operation were collected. Single-factor analysis and Spearman correlation analysis were employed to determine the risk factors of postoperative complications. Results: A total of 35,243 colonoscopy examinations were performed during the study period, of which 18 cases of colonoscopic perforation were included in the criteria. Most perforations occurred in the rectosigmoid junction (3 cases) and sigmoid colon (11 cases). All perforation patients received operational treatment, and the incidence of postoperative complications was 38.9%, but no deaths. There were 7 patients who developed postoperative complications. Spearman correlation analysis showed that preoperative medication of glucocorticoid and nonrectosigmoid perforation were positively related to postoperative complications (P < .05), while perforation diagnosed immediately and satisfying intestinal cleanliness were negatively related to it (P < .05). Conclusion: Perforation is a rare but serious complication of colonoscopy, which mostly occurs in the rectosigmoid junction and sigmoid colon. Laparoscopic primary repair is safe and feasible in resolving colonic perforation due to colonoscopy, and postoperative complications were significantly related to perforation site, preoperative medication of glucocorticoid, perforation diagnosis time, and intestinal cleanliness.

Management of colonoscopic perforation: a systematic review and treatment algorithm

BACKGROUND

The aim of this review is to evaluate and summarize the current strategies used in the management of colonoscopic perforations as well as propose a modern treatment algorithm.

METHODS

Articles published between January 2004 and January 2019 were screened. A total of 167 reports were identified in combined literature search, of which 61 articles were selected after exclusion of duplicate and unrelated articles. Only studies that reported on the management of endoscopic perforation in an adult population were retrieved for review. Case reports and case series of 8 patients or less were not considered. Ultimately, 19 articles were considered eligible for review.

RESULTS

A total of 744 cases of colonoscopic perforations were reported in 19 major articles. The cause of perforation was mentioned in 16 articles. Colonoscopic perforations were reported as a consequence of diagnostic colonoscopies in 222 cases and therapeutic colonoscopies in 248 cases. The site of perforation was mentioned in 486 cases. Sigmoid colon was the predominant site followed by the cecum. The management of colonoscopic perforations was reported in a total of 741 patients. Surgical intervention was employed in 75% of the patients, of these 15% were laparoscopic and 85% required laparotomy. The predominant surgical intervention was primary repair.

CONCLUSION

Management strategies of colon perforations depend upon the etiology, size, severity, location, available expertise, and general health status. Usually, peritonitis, sepsis, or hemodynamic compromise requires immediate surgical management. Endoscopic techniques are under continuous evolution. Newer developments have offered high success rate with least amount of post-procedure complications. However, there is a need for further studies to compare the newer endoscopic techniques in terms of success rate, cost, complications, and the affected part of colon.

The analysis of outcomes of surgical management for colonoscopic perforations: A 16-years experiences at a single institution

BACKGROUND/OBJECTIVE

Colonoscopy-induced colonic perforation often requires surgical management. The aim of this study was to analyze the outcomes after surgery for colonoscopic perforations (CPs).

METHODS

This was a retrospective chart review study of 48 patients who underwent surgery for CPs between January 2002 and May 2017. The patients were divided into two groups: Group I (n = 25) had diagnostic CPs, and Group II (n = 23) had therapeutic CPs.

RESULTS

The most common perforation sites in Group I were the sigmoid colon (n = 19; 76.0%), whereas in Group II were the transverse colon (n = 10, 43.5%) and sigmoid colon (n = 10, 43.5%; p = 0.013). The surgeries performed were primary closure (n = 16, [64.0%] Group I; n = 11 [47.8%] Group II) and bowel resection (n = 9 [36.0%] Group I; n = 11 [47.8%] Group II). The rate of temporary stomas was higher in Group II (n = 9, 26.1%) than Group I (n = 2, 8.0%; p = 0.030). The re-perforation rate after surgery was 8.0% (n = 2) in Group I and 8.7% (n = 2) in Group II (p = 0.568). These re-perforation patients all those who had a simple closure without a wedge resection. The conversion rate after laparoscopic surgery was 20.0% (n = 2 of 10) in Group I and 33.3% (n = 1 of 3) in Group II.

CONCLUSIONS

Surgical management is one of the important therapies in the treatment of CP. Simple primary closure without a wedge resection should be used cautiously. Therapeutic CPs was associated with more temporary stoma formation. The type of surgery should be carefully selected, depending on the type of CP.

Laparoscopic repair using an endoscopic linear stapler for management of iatrogenic colonic perforation during screening colonoscopy

Introduction

Colonoscopy is a safe and effective procedure, but it is also an inevitably invasive one. Laparoscopic repair of colonoscopic perforations has been reported to be a safe and effective treatment.

Aim

We present our surgical technique and outcomes of laparoscopic repairs using an endoscopic linear stapler for iatrogenic colonic perforation during screening colonoscopy.

Material and methods

Laparoscopic repair using an endoscopic linear stapler for iatrogenic colonic perforation during screening colonoscopy was performed by two experienced laparoscopic surgeons on 14 consecutive patients between April 2010 and December 2017 at our hospital. Using prospectively collected data, an observational study was performed on a per protocol basis.

Results

The mean age of the 14 patients who underwent laparoscopic repair was 56.6 ±9.1 years. The most common perforation site was the sigmoid colon in 10 (71.4%) patients, followed by the rectosigmoid junction in 3 (21.4%) patients and the splenic flexure in 1 (7.1%) patient. The median perforation size was 10 (range: 5–30) mm. The mean operation time was 73.9 ±28.2 min. Postoperative complications occurred in 1 (7.1%) patient. There was no postoperative mortality or reoperation within 30 days after surgery. The median time to tolerance of a regular diet was 5 (range: 3–6) days. The median postoperative hospital stay was 8.5 (range: 5–15) days.

Conclusions

Laparoscopic repair using an endoscopic linear stapler is a safe, easy, and effective surgical technique to treat colonic perforation related to screening colonoscopy.

Over-the-Scope Clip Closure of Pancreatico-Colonic Fistula Secondary to Acute or Chronic Pancreatitis: A Case Series

Introduction: Pancreatico-colonic fistula (PCF) is a rare adverse effect secondary to severe acute or chronic pancreatitis and potentially life-threatening because of abdominal sepsis. Over-the-scope clip (OTSC^®) system is a recently developed endoscopic device and has been successfully used for bleeding and perforations of the gastrointestinal tract. We hereby report a series of patients with PCFs in whom OTSC was used. Materials and Methods: From January 2011 to December 2018, we retrospectively collected data on cases of PCFs with endoscopic treatment using the OTSC system. After conservative management, the endoscopic intervention was carried out on patients in deep sedation by single skilled operators. Results: A total of 9 patients were enrolled and patients were treated with 14/6 t-type OTSC. PCF occurred secondary to chronic (n = 5) and acute pancreatitis (n = 4). There were no adverse effects related to the endoscopic procedure itself. Further endoscopic evaluation was performed 8 weeks later and revealed a successful fistula closure in 4 patients with chronic pancreatitis (80%) and in 2 patients with acute pancreatitis (50%). An insufficient fistula closure was observed in 3 cases because of dislocation of the OTSC and an additional surgical procedure was required. Conclusion: The OTSC system seems to be safe and effective in short-term management of PCFs because of acute or chronic pancreatitis in addition to the already established nonsurgical therapy. However, the OTSC closure of PCFs in patients with acute pancreatitis seems to be associated with a higher failure rate. To sum up, more evidence and long-term studies are needed to determine the criteria for the use of OTSC in closure of PCFs owing to acute or chronic pancreatitis.

Effect of submucosal injection of normal saline and glycerol fructose on endoscopic polypectomy in patients with colorectal polyps

Effect of submucosal injection of normal saline and glycerol fructose on endoscopic polypectomy in patients with colorectal polyps was investigated. A total of 275 patients with colorectal polyps were enrolled in this study and underwent endoscopic gastrointestinal polypectomy in Qingdao Chengyang People's Hospital from March 2013 to December 2016. Among them, 150 patients who underwent submucosal injection of glycerol fructose were set as the experimental group, and 125 patients who underwent submucosal injection of normal saline were set as the control group. The surgery conditions, complications and recurrence rates were compared between the two groups. The time of processing polyps and the total surgery time in the experimental group were shorter than those in the control group (P<0.05). The number of repeated injections in the experimental group was less than that in the control group, and the difference was statistically significant (P<0.05). The amount of fluid and propofol injected in patients of the experimental group was significantly lower than that of the control group, and the difference was statistically significant (P<0.05). The en bloc resection rate (EBRR) and complete resection rate (CRR) in the experimental group were 68.0 and 48.0%, respectively. EBRR and CRR in the control group were 49.6 and 27.2%, respectively. EBRR and CRR in the experimental group were significantly higher than those in the control group (P<0.05). After follow-up of the patients for 3 months, there was no significant difference in the recurrence rate between the two groups (P>0.05). The results indicated that endoscopic colorectal polypectomy with glycerol fructose as a submucosal injection can shorten the time of surgery, reduce the number of repeated injections, reduce the amount of fluid and propofol, and also improve EBRR and CRR.

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.

The Close Relationship between Large Bowel and Heart: When a Colonic Perforation Mimics an Acute Myocardial Infarction

Colonoscopic perforation is a serious and potentially life-threatening complication of colonoscopy. Its incidence varies in frequency from 0.016% to 0.21% for diagnostic procedures, but may be seen in up to 5% of therapeutic colonoscopies. In case of extraperitoneal perforation, atypical signs and symptoms may develop. The aim of this report is to raise the awareness on the likelihood of rare clinical features of colonoscopic perforation. A 72-year-old male patient with a past medical history of myocardial infarction presented to the emergency department four hours after a screening colonoscopy with polypectomy, complaining of neck pain, retrosternal oppressive chest pain, dyspnea, and rhinolalia. Right chest wall and cervical subcutaneous emphysema, pneumomediastinum, pneumoretroperitoneum, and bilateral subdiaphragmatic free air were reported on the chest and abdominal X-rays. The patient was treated conservatively, with absolute bowel rest, total parental nutrition, and broad-spectrum intravenous antibiotics. Awareness of the potentially unusual clinical manifestations of retroperitoneal perforation following colonoscopy is crucial for the correct diagnosis and prompt management of colonoscopic perforation. Conservative treatment may be appropriate in patients with a properly prepared bowel, hemodynamic stability, and no evidence of peritonitis. Surgical treatment should be considered when abdominal or chest pain worsens, and when a systemic inflammatory response arises during the conservative treatment period.

2017 WSES guidelines for the management of iatrogenic colonoscopy perforation

Iatrogenic colonoscopy perforation (ICP) is a severe complication that can occur during both diagnostic and therapeutic procedures. Although 45–60% of ICPs are diagnosed by the endoscopist while performing the colonoscopy, many ICPs are not immediately recognized but are instead suspected on the basis of clinical signs and symptoms that occur after the endoscopic procedure. There are three main therapeutic options for ICPs: endoscopic repair, conservative therapy, and surgery. The therapeutic approach must vary based on the setting of the diagnosis (intra- or post-colonoscopy), the type of ICP, the characteristics and general status of the patient, the operator’s level of experience, and surgical device availability.

Although ICPs have been the focus of numerous publications, no guidelines have been created to standardize the management of ICPs. The aim of this article is to present the World Society of Emergency Surgery (WSES) guidelines for the management of ICP, which are intended to be used as a tool to promote global standards of care in case of ICP. These guidelines are not meant to substitute providers’ clinical judgment for individual patients, and they may need to be modified based on the medical team’s level of experience and the availability of local resources.

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.

Over-the-scope clip closure for treatment of post-pancreaticogastrostomy pancreatic fistula: A case series

BACKGROUND AND AIM

The over-the-scope clip (OTSC) system is a recently developed endoscopic device. In the last few years, it has been successfully used for severe bleeding or deep wall lesions, or perforations of the gastrointestinal (GI) tract. We hereby report a series of patients with post-pancreaticogastrostomy pancreatic fistula in whom OTSC were used as endoscopic treatment.

METHODS

From January 2012 to July 2015, we prospectively collected data on cases of postoperative pancreatic fistula. These patients underwent pancreaticoduodenectomy in a high-volume center of hepatobiliopancreatic surgery. After conservative management, OTSC closure was done by single skilled operators in anesthesiologist-assisted deep sedation.

RESULTS

A total of seven patients were enrolled. According to the International Study Group of Pancreatic Surgery criteria, we observed grade B postoperative pancreatic fistula in all cases. All patients were treated with 12/6 t-type OTSC. In two cases, a second clip was successfully applied to a second site adjacent to the original closure site. In all cases, subsequent fluoroscopy showed no contrastographic spreading through the wall. There were no complications related to the procedure itself, not from the endoscopy point of view, nor from the anesthesiological perspective. There were no device malfunctions. Further clinical and endoscopic evaluation was made 8 weeks later and showed no fistula or anastomotic defect recurrence. No patients required additional endoscopic or interventional procedures.

CONCLUSION

In consideration of clinical and technical success, OTSC placement in POPF seems to be effective, safe and technically relatively easy to carry out.

Treatment Options in Gastrointestinal Cutaneous Fistulas

Enterocutaneous fistulas occur most commonly following surgery. A minority of them is caused by a myriad of other etiologies including infection, malignancy, and radiation. While some fistulas may close spontaneously, most patients will eventually need surgery to resolve this pathology. Successful treatment entails adoption of various methods of treatment aimed at control of sepsis, protection of surrounding skin and soft tissue, control of fistula output, and maintenance of nutrition, with eventual spontaneous or surgical closure of the fistula. The aim of this article is to review the various treatment options in their appropriate context.

Endoscopic repair of rectal perforation due to colonoscopy with a clamp method

Colon perforation during colonoscopy is a rare complication that usually requires surgical intervention. Traditionally, primary repair by laparoscopy, laparotomy, resection, and anastomosis is performed for such perforations. More recently developed minimally invasive endoscopic instruments have also been used in the repair of these perforations; this is becoming increasingly common. An endoscopic over-the-scope clip clamp was used in a 59-year-old male patient who suffered a rectum perforation in connection with a diagnostic colonoscopy. He was referred to our clinic. A colonoscopy was performed in our clinic to assess the rectal perforation caused by a diagnostic colonoscopy 2 h after the initial colonoscopy, with the concurrent therapeutic purpose of repairing the perforation using an endoscopic clamping method. Oral feeding was started 24 h after the procedure. After three days, the patient was discharged. An endoscopic clamping method in appropriate cases can be a safe and appropriate alternative therapy in the management of colonoscopic perforations.

The Outcomes of Management for Colonoscopic Perforation: A 12-Year Experience at a Single Institute

Purpose

Optimal management of colonoscopic perforation (CP) is controversial because early diagnosis and prompt management play critical roles in morbidity and mortality. Herein, we evaluate the outcomes and clinical characteristics of patients with CP according to treatment modality to help establish guidelines for managing CP.

Methods

Our retrospective analysis included 40 CP patients from January 1, 2003, to December 31, 2014. Patients with CP were categorized into 2 groups according to therapeutic modality: operation (surgery) and nonoperation (endo-luminal clip application or conservative treatment) groups.

Results

The postoperative morbidity rate was 40%, and no mortalities were noted. The incidence of abdominal pain and tenderness in patients who received only conservative management was significantly lower than in those who underwent surgery (P < 0.001 and P = 0.004, respectively). Patients tended to undergo surgery more often for diagnosis times longer than 24 hours and for diagnostic CPs. The mean hospital stays for the operation and nonoperation groups were 14.6 ± 7.77 and 5.9 ± 1.62 days, respectively (P < 0.001). Compared to the operation group, the nonoperation group began intake of liquid diets significantly earlier after perforation (3.8 ± 1.32 days vs. 5.6 ± 1.25 days, P < 0.001) and used antibiotics for a shorter duration (4.7 ± 1.29 days vs. 8.7 ± 2.23 days, P < 0.001).

Conclusion

The time of diagnosis and the injury mechanism may be useful indications for conservative management. Nonoperative management, such as endo-luminal clip application, might be beneficial, when feasible, for the treatment of patients with CP.

Complications of diagnostic colonoscopy, upper endoscopy, and enteroscopy

Endoscopy is an inherent and an invaluable tool in every gastroenterologist's armamentarium. The prerequisite for quality and safety remains foremost. Adverse events should be minimized and proactive steps should taken before, during and after the endoscopic procedure. Upper endoscopy and colonoscopy are part of basic endoscopy and their major complications will be reviewed here, together with those of enteroscopy. The most common of all endoscopy related complications are cardiopulmonary and thus they will be addressed in detail first. Colonoscopy's major complications are bleeding and perforation. Their epidemiology, mechanisms/risk factors, diagnosis, treatment and prevention will be addressed. The incidence of both of these complications increases significantly with polypectomy. Thus clinical judgment and experience in both polypectomy techniques and the ways to treat these complications, especially with the advanced endoscopic options advanced in the last decade, are of paramount importance. Post-polypectomy syndrome, infection and gas explosion are less frequent and will be reviewed briefly. Bleeding and perforation are upper endoscopy's major complications as well. Advances in endoscopic techniques in recent years offer endoscopic treatment instead of directly resorting to surgery, as was used to be the case and still is if the first fails. Enteroscopy is generally a more advanced procedure and overall complication rate is often quoted as 1%, most of them have been attributed to the passage of the overtube. Perforation and bleeding are the major complications, and a unique upper enteroscopy-associated complication is pancreatitis.

Endoscopic management of colonic perforations: clips versus suturing closure (with videos)

BACKGROUND AND AIMS

Perforation during colonoscopy remains the most worrisome adverse event and usually requires urgent surgical rescue. The aim of this study was to evaluate the feasibility and effectiveness of endoscopic closure of full-thickness colonic perforations.

METHODS

We performed a retrospective analysis of all consecutive patients with endoscopically closed colonic perforations over the past 6 years (2009-2014). Colonic perforations were closed by using endoscopic clips or an endoscopic suturing device. Most patients were admitted for treatment with intravenous antibiotics and kept on bowel rest. If their clinical condition deteriorated, urgent surgery was performed. If patients remained stable, oral feeding was resumed, and patients were discharged with subsequent clinical and endoscopic follow-up.

RESULTS

Twenty-one patients had iatrogenic colonic perforations closed with an endoscopic suturing device or endoscopic clips during the study period. Primary closure of a colonic perforation was performed with endoscopic clips in 5 patients and sutured with an endoscopic suturing device in 16 patients. All 5 patients after clip closure had worsening of abdominal pain and required laparoscopy (4 patients) or rescue colonoscopy with endoscopic suturing closure (1 patient). Two patients had abdominal pain after endoscopic suturing closure, but diagnostic laparoscopy confirmed complete and adequate endoscopic closure of the perforations. The other 15 patients did not require any rescue surgery or laparoscopy after endoscopic suturing. The main limitation of our study is its retrospective, single-center design and relatively small number of patients.

CONCLUSION

Endoscopic suturing closure of colonic perforations is technically feasible, eliminates the need for rescue surgery, and appears more effective than closure with hemostatic endoscopic clips.

Over-the-Scope Clip (OTSC) System for Sleeve Gastrectomy Leaks

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is currently being widely accepted for its role in the treatment of morbid obesity. Staple-line leakage is one of the most reported complications found in 0.5-7 % of the population, in which the Over-the-Scope Clip (OTSC) (Ovesco Endoscopy, Tübingen, Germany), a novel device, is employed. We present our experience with this system in LSG leaks.

METHODS

A retrospective analysis of prospectively collected data from patients with LSG leakage was performed, and these patients were treated with the OTSC system. Efficiency was defined as complete oral nutrition without any evidence of additional leakage.

RESULTS

Overall, 26 patients underwent endoscopic OTSC treatment. The median age was 39 years (range 26-60), and 12 were male patients (46.15 %). The mean body mass index (BMI) was 42.89 kg/m(2), and 10 patients (38.46 %) came from a revisional bariatric procedure (SRVG or LAGB). Twenty-two patients (84.61 %) had upper staple-line leaks (near the GEJ), and the remaining 4 (15.38 %) had lower antral leaks. Number of endoscopy sessions ranged from 2 to 7 (median 3). There were five failures: 2 of them had an antral leak, and the remaining 3 had an upper staple-line leak. Twenty-one (80.76 %) leaks were successfully treated within 32 days' median time till complete oral nutrition was attained (range 14-70).

CONCLUSIONS

The success rate was high with the OTSC system, and it is concluded to be a safe and effective treatment for LSG leaks.

Endoscopic closure of acute perforations of the GI tract: a systematic review of the literature

BACKGROUND

Surgical repair of endoscopic perforations of the GI tract used to be the standard, but immediate, secure endoscopic closure has become an attractive alternative treatment with the potential to reduce morbidity and mortality.

OBJECTIVE

We aimed to perform a systematic review of the medical literature on endoscopic closure of acute iatrogenic perforations of the GI tract.

DESIGN

A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines.

SETTING

Available medical literature from 1966 through November 2013.

PATIENTS

Patients with an acute perforation after an endoscopic procedure that was closed endoscopically.

INTERVENTIONS

Endoscopic closure of an acute perforation of the GI tract.

MAIN OUTCOME MEASUREMENTS

Clinically successful endoscopic closure.

RESULTS

In our search, we identified 726 studies, 702 of which had to be excluded. Twenty-four cohort studies (21 retrospective, 3 prospective) were included in the analysis. No randomized trials were identified. Overall, the methodological quality was low. The 24 studies included described 466 acute perforations in which endoscopic closure was attempted. Successful endoscopic closure was achieved in 419 cases (89.9%; 95% CI, 87%-93%). Successful closure was achieved in 90.2% (n = 359; 95% CI, 87%-93%) of cases by using endoclips, in 87.8% (n = 58; 95% CI, 78%-95%) by using the over-the-scope-clip, and in 100% (n = 2) by using a metal stent.

LIMITATIONS

Low methodological quality of included studies.

CONCLUSION

This systematic review suggests that endoscopic perforation closure is a safe and effective alternative for surgical intervention in selected cases; however, the overall methodological quality was low. Prospective, true consecutive studies are needed to define the definitive role of endoscopic closure of perforations.

Endoscopic clips for the closure of acute iatrogenic perforations: Where do we stand?

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.

Complications during colonoscopy: prevention, diagnosis, and management

Colonoscopy is largely performed in daily clinical practice for both diagnostic and therapeutic purposes. Although infrequent, different complications may occur during the examination, mostly related to the operative procedures. These complications range from asymptomatic and self-limiting to serious, requiring a prompt medical, endoscopic or surgical intervention. In this review, the complications that may occur during colonoscopy are discussed, with a particular focus on prevention, diagnosis, and therapeutic approaches.

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.

Adverse events related to colonic endoscopic mucosal resection and polypectomy

Colonoscopy is a commonly performed procedure. The rate of adverse events is 2.8 per 1000 screening colonoscopies. These adverse events include cardiovascular and pulmonary events, abdominal pain, hemorrhage, perforation, postpolypectomy syndrome, infection, and death. Serious adverse events, such as hemorrhage and perforation, occur most frequently when colonoscopy is performed with polypectomy. This article highlights the prevention and management of adverse events associated with polypectomy and endoscopic mucosal resection of colonic lesions.

Endoscopic Treatment of Various Gastrointestinal Tract Defects with an Over-the-Scope Clip: Case Series from a Tertiary Referral Hospital

Recently, increasingly invasive therapeutic endoscopic procedures and more complex gastrointestinal surgeries such as endoscopic mucosal resection, endoscopic submucosal dissection, and novel laparoscopic approaches have resulted in endoscopists being confronted more frequently with perforations, fistulas, and anastomotic leakages, for which nonsurgical closure is desired. In this article, we present our experiences with the use of over-the-scope clip (OTSC) for natural orifice transluminal endoscopic surgery (NOTES) closure, prevention of perforation, anastomotic leakages, and fistula closures. The OTSC is a valuable device for closing intestinal perforations and fistulas, for NOTES closure, and for the prevention of perforation after the excision of a tumor from the proper muscle layer. Furthermore, it seems to be quite safe to perform, even by endoscopists with little experience of the technique.

Lower rate of colonoscopic perforation: 110,785 patients of colonoscopy performed by colorectal surgeons in a large teaching hospital in China

BACKGROUND

Colonoscopic perforation (CP) has a low incidence rate. However, with the extensive use of colonoscopy, even low incidence rates should be evaluated to identify and address risks. Information on CP is quite limited in China.

OBJECTIVE

Our study aimed to determine the frequency of CP in colonoscopies performed by surgeons at a large teaching hospital in China over a 12-year period.

METHODS

A retrospective review of medical records was performed for all patients who had CPs from 1 January 2000 to 31 December 2012. Iatrogenic perforations were identified mainly by abdominal X-ray or computed tomography scan. Follow-up information of adverse events post-colonoscopy was identified from the colorectal surgery database of our hospital. Patients' demographic data, colonoscopy procedure information, location of perforation, treatment, and outcome were recorded.

RESULTS

A total of 110,785 diagnostic and therapeutic colonoscopy procedures were performed (86,800 diagnostic cases and 23,985 therapeutic cases) within the 12-year study period. A total of 14 incidents (0.012%) of CP were reported (seven males and seven females), of which nine cases occurred during diagnostic colonoscopy (0.01%) and five after therapeutic colonoscopy (three polypectomy cases, one endoscopic mucosal resection, and one endoscopic mucosal dissection). Mean patient age was 67.14 years. One case of CP (7.14%) after colonoscopy polypectomy was treated using curative colonoscopy endoclips. Other patients underwent operations: six cases (46.15%) of primary repair, four cases (28.57%) of resection with anastomosis, and two cases (15.38%) of resection without anastomosis. No obvious perforation was found in one patient (7.69%). Surgeons attempted to treat one case laparoscopically but eventually resorted to open surgery. The postoperative course was uncomplicated in eight cases (57.14%) and complicated in six cases (42.86%) but without mortality.

CONCLUSION

CP is a serious but rare complication of colonoscopy. A perforation risk of 0.012% was found in our study. The optimal management of CP remains controversial. Treatment for CP should be individualized according to the patient's condition, related devices, and surgical skills of endoscopists or surgeons. Selective measures such as colonoscopy without intravenous sedation and decrease of loop formation can effectively reduce rates of perforation.

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.

Perforation following colorectal endoscopy: what happens beyond the endoscopy suite?

BACKGROUND

The risk factors for perforation from colorectal endoscopy have been well studied, but little is known about clinical outcomes beyond the immediate event.

OBJECTIVE

To evaluate short- and long-term outcomes of iatrogenic colorectal perforation following colorectal endoscopy.

DESIGN

Retrospective review over 16 years at a single tertiary care institution.

MAIN OUTCOME MEASURES

Treatment interventions, morbidity and mortality rates, hospital length of stay, stoma closure rate, and long-term complications.

RESULTS

Of 132,259 colorectal endoscopies, 26 patients (0.02%) had a perforation (54% males; mean age, 67 years). The rectosigmoid colon was the most common site of perforation (65%). Thirty-eight percent of the perforations were recognized at the time of procedure, 31% presented within 24 hours, and 31% presented beyond 24 hours. Operative repair was undertaken in 85% of the patients, and 15% were managed with inpatient hospital observation. Primary repair was performed in 68% (defunctioning stoma in 18%). Mean hospital length of stay was 10.1 days. The overall postoperative complications rate was 55%, and wound complications were noted in 45%. The 30-day mortality rate was 19%. No death was observed beyond the first month. American Society of Anesthesiologists physical status Classes 3 and 4 were associated with mortality (p = 0.004). Of 7 patients who received a stoma, only 2 patients (29%) had stoma reversal. Long-term complications included incisional hernia (10%) and small-bowel obstruction (5%).

CONCLUSIONS

Perforation following colorectal endoscopy was uncommon in this study but was associated with significant morbidity and mortality. An increased risk of death was noted with higher American Society of Anesthesiologists physical status class.

Enterovesical fistulae: aetiology, imaging, and management

Background and Study Objectives. Enterovesical fistula (EVF) is a devastating complication of a variety of inflammatory and neoplastic diseases. Radiological imaging plays a vital role in the diagnosis of EVF and is indispensable to gastroenterologists and surgeons for choosing the correct therapeutic option. This paper provides an overview of the diagnosis of enterovesical fistulae. The treatment of fistulae is also briefly discussed. Material and Methods. We performed a literature review by searching the Medline database for articles published from its inception until September 2013 based on clinical relevance. Electronic searches were limited to the keywords: "enterovesical fistula," "colovesical fistula" (CVF), "pelvic fistula", and "urinary fistula". Results. EVF is a rare pathology. Diverticulitis is the commonest aetiology. Over two-thirds of affected patients describe pathognomonic features of pneumaturia, fecaluria, and recurrent urinary tract infections. Computed tomography is the modality of choice for the diagnosis of enterovesical fistulae as not only does it detect a fistula, but it also provides information about the surrounding anatomical structures. Conclusions. In the vast majority of cases, this condition is diagnosed because of unremitting urinary symptoms after gastroenterologist follow-up procedures for a diverticulitis or bowel inflammatory disease. Computed tomography is the most sensitive test for enterovesical fistula.

Endoclip closure of a large colonic perforation following colonoscopic leiomyoma excision

BACKGROUND AND OBJECTIVE

Endoscopic removal of large colonic submucosal lesions can lead to a higher risk of perforation. Although not as common following diagnostic and therapeutic colonoscopy, it does occur more often following therapeutic colonoscopy. We present a case of a large submucosal mass excised endoscopically, resulting in a large perforation that was closed using endoclips. While endoclips are typically used for smaller perforations, we have found that they can be used safely on a larger defect.

METHODS

A 68-y-old woman presented with a 2.9-cm benign submucosal mass found in the hepatic flexure. It was removed via endoscopic polypectomy, leaving a perforation of 3cm x 3cm. The perforation was closed with endoscopic clips.

RESULTS

Histology of the specimen showed clear margins. At 4-wk follow-up, the patient had no complications. A colonoscopy at 6-mo follow-up showed only a scar at the procedure site with no complaints.

CONCLUSIONS

Large iatrogenic colonic perforations can be managed successfully using endoclips, particularly in a prepped colon.

Efficacy of cap-assisted endoscopy for routine examining the ampulla of Vater

AIM: To determine the efficacy of a cap-assisted endoscopy (CAE) to completely visualize the ampulla of Vater (AV) in patients failed by conventional endoscopy.

METHODS: A prospective study was conducted on 120 patients > 20 years of ages who visited the Health Promotion Center of Chungbuk National University Hospital for conscious sedation esophagogastroduodenoscopy (EGD) as a screening test from July to October, 2011. First, forward-viewing endoscopy was performed with reasonable effort using a push and pull method. We considered complete visualization of the AV when we could observe the entire AV including the orifice clearly, and reported the observation as complete or incomplete (partial or not found at all). Second, in cases of complete failure of the observation, an additional AV examination was conducted by attaching a short cap (D-201-10704, Olympus Medical Systems, Tokyo, Japan) to the tip of a forward-viewing endoscope. Third, if the second method failed, we replaced the short cap with a long cap (MH-593, Olympus Medical Systems) and performed a re-examination of the AV.

RESULTS: Conventional endoscopy achieved complete visualization of the AV in 97 of the 120 patients (80.8%) but was not achieved in 23 patients (19.2%). Age (mean ± SD) and gender [male (%)] were not significantly different between the complete observation and the incomplete observation groups. Additional short CAE was performed in patients in whom we could not completely visualize the AV. This group included 13 patients (10.9%) with partial observation of the AV and 10 (8.3%) in which the AV was not found. Short CAE permitted a complete observation of the AV in 21 of the 23 patients (91.3%). Patients in whom visualization of the AV failed with short CAE had satisfactory outcomes by replacing the short cap with a long cap. The additional time for CAE took an average of 141 ± 88 s. There were no complications and no significant mucosal trauma.

CONCLUSION: CAE is safe to use as a salvage method to achieve complete visualization of the AV when a regular EGD examination fails.

Laparoscopic Primary Colorrhaphy for Acute Iatrogenic Perforations during Colonoscopy

Purpose. We present our experience with laparoscopic colorrhaphy as definitive surgical modality for the management of colonoscopic perforations. Methods. Over a 17-month period, we assessed the outcomes of consecutive patients presenting with acute colonoscopic perforations. Patient characteristics and perioperative parameters were tabulated. Postoperative outcomes were evaluated within 30 days following discharge. Results. Five female patients with a mean age of 71.4 ± 9.7 years (range: 58–83), mean BMI of 26.4 ± 3.4 kg/m² (range: 21.3–30.9), and median ASA score of 2 (range: 2-3) presented with acute colonoscopic perforations. All perforations were successfully managed through laparoscopic colorrhaphy within 24 hours of development. The perforations were secondary to direct trauma (n = 3) or thermal injury (n = 2) and were localized to the sigmoid (n = 4) or cecum (n = 1). None of the patients required surgical resection, diversion, or conversion to an open procedure. No intra- or postoperative complications were encountered. The mean length of hospital stay was 3.8 ± 0.8 days (range: 3–5). There were no readmissions or reoperations. Conclusion. Acute colonoscopic perforations can be safely managed via laparoscopic primary repair without requiring resection or diversion. Early recognition and intervention are essential for successful outcomes.

Performance of the OTSC System in the endoscopic closure of iatrogenic gastrointestinal perforations: a systematic review

BACKGROUND

Reliable closure is a prerequisite for conventional and innovative endoscopic procedures, such as NOTES. The purpose of this study is the systematic evaluation of the procedural and clinical success rates in closure of iatrogenic gastrointestinal perforations and acute anastomotic leaks by means of the over-the-scope-clip system (OTSC(®)).

DESIGN

PubMed and other sources were searched systematically for clinical and preclinical research on the evaluation of the OTSC System for closure of gastrointestinal perforations and leaks. Appraisal of studies for inclusion and data extraction was performed independently by two reviewers using an a priori determined data extraction grid. Major endpoints to be extracted were data on procedural success (successful clip application) and clinical access (durable closure of defect without secondary adjunct therapy).

RESULTS

A total of 17 clinical research articles/abstracts and 22 preclinical research articles/abstracts were identified. The examined clinical studies comprised case series and clinical single-arm studies. The reviewed studies revealed a consistently high mean rate of procedural success of 80-100 % and durable clinical success of 57-100 %. An identified major drawback preventing successful clip application was occurrence of fibrotic or inflamed lesion edges. Usage of the OTSC System was accompanied by neither major clip-related nor application-related complication. In experimental settings, closure of larger perforations and gastric access sites of NOTES or endoscopic full-thickness resection were achieved with high rates of success.

CONCLUSIONS

Because randomized, clinical trials are not available in this field of indication, the evaluation is based on small case series. Nevertheless, by pooling all experience gained, we conclude that endoscopic closure of iatrogenic gastrointestinal perforations and acute anastomotic leaks by means of the OTSC System is a safe and effective method.

Laparoscopic conservative surgery of colovesical fistula: is it the right way?

Enterovesical fistula is a rare disease. The standard treatment of colovesical fistula is removal of the fistula, suture of the bladder wall, and colic resection with or without temporary colostomy. The usual approach is open because the laparoscopic one has high conversion rates and morbidity. We report the first laparoscopic conservative treatment of colovesical fistula in our knowledge and its long-term results. A 69-year-old man was affected by colovesical fistula due to endoscopic exeresis of a 2 cm adenomatous polyp in the sigmoid diverticulum. We performed a laparoscopic conservative treatment of the fistula without colic resection. Operative time was 210 min and estimated blood loss was 300 ml. The catheter was removed after 10 days. Time to first flatus was 2 days and the hospital stay was 8 days. No peri- or post-operative complications occurred. At 48-month follow-up fistula did not recur. Laparoscopic conservative surgery for colovesical fistula is safe and feasible. It could be a therapeutic option in selected cases, especially if diverticular disease and inflammation are slight.

Efficacy of the over-the-scope clip (OTSC) for treatment of colorectal postsurgical leaks and fistulas

BACKGROUND

Colorectal postsurgical leaks and fistulas are severe complications that dramatically increase morbidity and mortality. The aim of this study was to evaluate the clinical impact of over-the-scope clip (OTSC) closure to seal the visceral wall in the management of acute and chronic colorectal postsurgical leaks and fistulas.

METHODS

We reviewed our prospective series of acute and chronic colorectal postsurgical leaks and fistulas observed between April 2008 and September 2011 and treated by OTSC. Indications were all cases with an orifice <15 mm in maximum diameter with no extraluminal abscess and luminal stenosis.

RESULTS

Endoscopic OTSC closure was performed in 14 consecutive patients (mean defect = 9.1 mm in diameter) by means of 10.5- or 12-mm clips, depending on the wall defect diameter. In eight cases, the indication was an acute leak and in six cases a chronic leak, mainly after anterior rectal resection; two cases were complicated by a rectovaginal fistula and in two other cases by a colocutaneous fistula. OTSC treatment was used to complete endoscopic vacuum-assisted closure of a large defect in three cases. The overall success rate was 86 % (12/14): 87 % (7/8) in acute and 83 % (5/6) in chronic cases. No OTSC-related complications occurred. Further surgery was required in one case.

CONCLUSION

Endoscopic OTSC closure of colorectal postsurgical leaks and fistulas is a safe technique, with a high success rate in both acute and chronic cases, including rectovaginal and colocutaneous fistulas.

Endoscopic complications--avoidance and management

The frequency of endoscopic complications is likely to rise owing to the increased number of indications for therapeutic procedures and also to the increased complexity of endoscopic techniques. Informed patient consent should be obtained as part of the procedure. Prevention of endoscopic adverse events is based on knowledge of the relevant risk factors and their mechanisms of occurrence. Thus, suitable training of future gastroenterologists and endoscopists is required for these complex procedures. When facing a complication, appropriate management is generally provided by an early diagnosis followed by prompt therapeutic care tailored to the situation. The most common complications of diagnostic and therapeutic upper gastrointestinal endoscopy, retrograde cholangiopancreatography, small bowel endoscopy and colonoscopy are reviewed here. Different modalities of medical, endoscopic or surgical management are also considered.

Endoskopische Möglichkeiten der Behandlung von Nahtinsuffizienzen im Rektum

<b><i>Hintergrund: </i></b>Anastomoseninsuffizienzen stellen eine gefürchtete Komplikation der kolorektalen Chirurgie dar. Endoskopische Techniken haben sich in der Therapie der Leckagen zunehmend etabliert. In dieser Übersicht möchten wir einen Überblick der wichtigsten endoskopischen Verfahren geben. <b><i>Methode: </i></b>Systematische Recherche der vorhandenen Literatur. <b><i>Ergebnisse: </i></b>Die bedeutendsten endoskopischen Verfahren zur Behandlung der kolorektalen Anastomoseninsuffizienzen stellen die Fibrininjektion, die Vakuumschwammtherapie (Endo-Sponge), spezielle Clip-Systeme (OTSC) sowie die Stentimplantation dar. Der breiten klinischen Anwendung dieser Verfahren steht jedoch eine unzureichende Studienlage gegenüber. <b><i>Schlussfolgerung: </i></b>Die Einschätzung der Wertigkeit der einzelnen endoskopischen Verfahren untereinander und in speziellen therapeutischen Situationen hängt im Wesentlichen von der Erfahrung der Untersucher ab. Es bedarf der Durchführung randomisierter, prospektiver Studien, um diese Erfahrungen zu objektivieren.

Endoscopic closure of colonic fistulas in colon cancer patients using a combination of hemoclips and endoloops: two case reports

Chronic colon fistulas, which commonly result from operative complications, are generally managed surgically. We present an endoscopic technique of fistula closure that involves the combined use of hemoclips and endoloops. Two consecutive patients with colonic fistulas that were refractory to conservative treatment were successfully managed with this new endoluminal technique. This minimally invasive treatment modality affords accurate localization of the fistula orifice and results in a low mortality and morbidity rates.