Yes, we can: reliable colonic closure with the Padlock-G clip in a survival porcine study (with video)

Cholecystocolic fistula closed using endoscopic therapy alone: A case report

BACKGROUND

Cholecystocolic fistula (CCF) is a known but rare complication of cholelithiasis. Treatment for CCF is generally surgical. As the number of elderly patients has increased in recent years, many cases require non-surgical treatment; therefore, endoscopic treatment has gained importance.

PATIENT CONCERNS AND DIAGNOSIS

An 87-year-old woman presented with impaired consciousness and symptoms of anorexia. Computed tomography showed cholecystitis and a fistula between the gallbladder and transverse colon. Colonoscopy revealed a CCF. The condition was diagnosed as CCF caused by acute cholecystitis.

INTERVENTIONS AND OUTCOMES

The patient declined surgery due to her age. Endoscopic fistula closure was performed using a through-the-scope clip after endoscopic naso-gallbladder drainage. Successful closure of the fistula resulted in improvement of cholecystitis and anorexia. The patient was discharged after one month. It has been more than 18 months since the procedure, there has been no recurrence.

CONCLUSION

This report on successful endoscopic closure of a CCF indicates that it may be useful for patients who decline surgery.

Gastrointestinal fistula endoscopic closure techniques

With the improvement in flexible endoscopic technology and the availability of new endoscopic devices, current endoscopic therapies spare many patients who would otherwise undergo surgical repair of gastrointestinal fistulas. These endoscopic techniques include gastrointestinal stents, endoscopic suturing, cardiac septal occluders, endo-sponge, vacuum therapy and others. This review elaborates on the indications, evidence, procedural details, efficacy, and complications of various endoscopic techniques for the management of gastrointestinal fistulas.

Endoscopic management of perforations, leaks and fistulas

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

Non-visible colovesical fistula located by cystoscopy and successfully managed with the novel Padlock® device for endoscopic closure

INTRODUCTION

The development of novel mechanical endoscopic closure systems allows now the management of some gastrointestinal fistula types in a minimally invasive way. However, the correct location of the fistulous tract is essential to achieve successful endoscopic closure.

CASE REPORT

A 69-year-old woman with high risk for surgery presented with recurrent cystitis, pneumaturia, and enteruria 2 months after medical-treated diverticulitis. Computerized tomography demonstrated colovesical fistula but colonoscopy could not locate the fistulous opening. A cystoscopy was performed and the fistulous tract was shown using a guidewire. Then, a novel over-the-scope clip device Padlock^® system was released in the sigmoid colon, with successful endoscopic closure through this not previously described collaborative approach between urologists, surgeons, and gastroenterologists.

Hepatocolic fistula managed with a novel Padlock® device for endoscopic closure

Recent advances in endoscopic therapeutics allow conditions such as fistulas of the digestive system to be treated endoscopically. These cases were recently managed with surgery. The Padlock® system includes a nitinol clip that was recently introduced for endoscopic therapy. There are few reports with regard to its use in the daily clinical practice. We report a case of a colonic fistula that was endoscopically managed with this novel over-the-scope nitinol clip system.

Over-the-scope clip-assisted endoscopic full-thickness resection of epithelial and subepithelial GI lesions

BACKGROUND AND AIMS

Endoscopic full-thickness resection (EFTR) allows for definitive diagnosis and treatment of select subepithelial and epithelial lesions unsuitable to conventional resection techniques. Our aim was to evaluate the efficacy and safety of over-the-scope (OTS) clip-assisted EFTR for these lesions.

METHODS

Patients who underwent OTS clip-assisted EFTR between June 2014 and October 2015 were analyzed. The procedure involved (1) thermal marking of the periphery of the lesion; (2) lesion suction into the cap of either an OTSC (Ovesco Endoscopy AG, Tübingen, Germany) or Padlock clip (Aponos Medical Corp, Kingston, NH, USA) with or without triprong anchor retraction of the lesion; (3) clip deployment; and (4) en bloc resection of the lesion above the clip using an electrosurgical snare and/or knife. Data were abstracted for demographics, lesion features, histopathologic diagnoses, R0 resection (negative margins) status, and adverse events.

RESULTS

Nine patients (7 men) with a mean age of 63 ± 9.6 years were identified. The endoscopic findings included subepithelial lesions in the duodenum (n = 4), rectosigmoid colon (n = 2), stomach (n = 1), and postappendectomy appendiceal orifice polyps (n = 2). The mean lesion size was 8 ± 3 mm and the mean procedure time 53 ± 21 minutes. R0 resection was confirmed in all cases. The histopathologic diagnoses included neuroendocrine tumors (n = 6), sessile serrated adenomas (n = 2), and pancreatic heterotopia (n = 1). No adverse events were noted.

CONCLUSIONS

OTS clip-assisted EFTR is an effective and safe technique for the removal of select subepithelial and epithelial lesions that are not amenable to conventional resection techniques.

Current treatment of tracheoesophageal fistula

Tracheoesophageal fistulas (TEFs) often occur with esophageal or bronchial carcinoma. Currently, we rely on implantation of delicate devices, such as self-expanding and silicone stents, in the esophagus or trachea to cover the fistula and expand the stenosis in order to relieve patient pain. However, because each case is different, our approach may not be effective for every patient. Consequently, new devices and technology have emerged to address these situations, such as degradable stents, Amplatzer^® devices, endobronchial one-way umbrella-shaped valves, and transplantation of mesenchymal stem cells. Although some studies have shown such alternatives can be reasonable solutions in special cases, further development of other new and effectual techniques is of utmost importance.

Novel endoscopic over-the-scope clip system

This paper reports our experience with a new over-the-scope clip in the setting of recurrent bleeding and oesophageal fistula. We treated five patients with the over-the-scope Padlock Clip™. It is a nitinol ring, with six inner needles preassembled on an applicator cap, thumb press displaced by the Lock-It™ delivery system. The trigger wire is located alongside the shaft of the endoscope, and does not require the working channel. Three patients had recurrent bleeding lesions (bleeding rectal ulcer, post polypectomy delayed bleeding and duodenal Dieulafoy's lesion) and two patients had a persistent respiratory-esophageal fistula. In all patients a previous endoscopic attempt with standard techniques had been useless. All procedures were conducted under conscious sedation but for one patient that required general anaesthesia due to multiple comorbidities. We used one Padlock Clip™ for each patient in a single session. Simple suction was enough in all of our patients to obtain tissue adhesion to the instrument tip. A remarkably short application time was recorded for all cases (mean duration of the procedure: 8 min). We obtained technical and immediate clinical success for every patient. No major immediate, early or late (within 24 h, 7 d or 4 wk) adverse events were observed, over follow-up durations lasting a mean of 109.4 d. One patient, treated for duodenal bulb bleeding from a Dieulafoy's lesion, developed signs of mild pancreatitis 24 h after the procedure. The new over-the-scope Padlock Clip™ seems to be simple to use and effective in different clinical settings, particularly in "difficult" scenarios, like recurrent bleeding and respiratory-oesophageal fistulas.

Novel endoscopic over-the-scope clip system

This paper reports our experience with a new over-the-scope clip in the setting of recurrent bleeding and oesophageal fistula. We treated five patients with the over-the-scope Padlock Clip™. It is a nitinol ring, with six inner needles preassembled on an applicator cap, thumb press displaced by the Lock-It™ delivery system. The trigger wire is located alongside the shaft of the endoscope, and does not require the working channel. Three patients had recurrent bleeding lesions (bleeding rectal ulcer, post polypectomy delayed bleeding and duodenal Dieulafoy’s lesion) and two patients had a persistent respiratory-esophageal fistula. In all patients a previous endoscopic attempt with standard techniques had been useless. All procedures were conducted under conscious sedation but for one patient that required general anaesthesia due to multiple comorbidities. We used one Padlock Clip™ for each patient in a single session. Simple suction was enough in all of our patients to obtain tissue adhesion to the instrument tip. A remarkably short application time was recorded for all cases (mean duration of the procedure: 8 min). We obtained technical and immediate clinical success for every patient. No major immediate, early or late (within 24 h, 7 d or 4 wk) adverse events were observed, over follow-up durations lasting a mean of 109.4 d. One patient, treated for duodenal bulb bleeding from a Dieulafoy's lesion, developed signs of mild pancreatitis 24 h after the procedure. The new over-the-scope Padlock Clip™ seems to be simple to use and effective in different clinical settings, particularly in “difficult” scenarios, like recurrent bleeding and respiratory-oesophageal fistulas.

Endoscopic management of gastrointestinal perforations, leaks and fistulas

Gastrointestinal perforations, leaks and fistulas may be serious and life-threatening. The increasing number of endoscopic procedures with a high risk of perforation and the increasing incidence of leakage associated with bariatric operations call for a minimally invasive treatment for these complications. The therapeutic approach can vary greatly depending on the size, location, and timing of gastrointestinal wall defect recognition. Some asymptomatic patients can be treated conservatively, while patients with septic symptoms or cardio-pulmonary insufficiency may require intensive care and urgent surgical treatment. However, most gastrointestinal wall defects can be satisfactorily treated by endoscopy. Although the initial endoscopic closure rates of chronic fistulas is very high, the long-term results of these treatments remain a clinical problem. The efficacy of endoscopic therapy depends on several factors and the best mode of treatment will depend on a precise localization of the site, the extent of the leak and the endoscopic appearance of the lesion. Many endoscopic tools for effective closure of gastrointestinal wall defects are currently available. In this review, we summarized the basic principles of the management of acute iatrogenic perforations, as well as of postoperative leaks and chronic fistulas of the gastrointestinal tract. We also described the effectiveness of various endoscopic methods based on current research and our experience.

New Technologies and Approaches to Endoscopic Control of Gastrointestinal Bleeding

Endoscopic treatment of gastrointestinal (GI) bleeding is considered the first line of therapy. Although standard techniques, such as epinephrine injection, through-the-scope hemoclips, bipolar coagulation, argon plasma coagulation, and band ligation are routinely used, some GI bleeds are refractory to these therapies. Newer technologies have emerged to assist with the treatment of GI bleeding. This article highlights endoscopic and endoscopic ultrasound-guided therapies that may be used by experienced endoscopists for the primary control of GI bleeding or for cases refractory to standard hemostatic techniques.

Emerging endoscopic therapies for nonvariceal upper gastrointestinal bleeding

Several new devices and innovative adaptations of existing modalities have emerged as primary, adjunctive, or rescue therapy in endoscopic hemostasis of gastrointestinal hemorrhage. These techniques include over-the-scope clip devices, hemostatic sprays, cryotherapy, radiofrequency ablation, endoscopic suturing, and endoscopic ultrasound-guided angiotherapy. This review highlights the technical aspects and clinical applications of these devices in the context of nonvariceal upper gastrointestinal bleeding.

Endoscopic band ligation for closure of GI perforations in a porcine animal model (with video)

BACKGROUND

GI perforations occur rarely during endoscopy but have life-threatening implications.

OBJECTIVE

To evaluate endoscopic band ligation (EBL) for closure of acute GI perforations by using a porcine model.

DESIGN

Investigator-initiated interventional pilot study by using an in vivo porcine model.

SETTING

Tertiary-care institution.

SUBJECTS

Ten domestic pigs.

INTERVENTION

Each animal underwent a single endoscopic procedure, with creation of a single GI lumen perforation. Perforations of 10 to 20 mm were created in the esophagus, stomach, duodenum, and colon. EBL was used for closure. Fourteen days later, the pigs were killed, microbial cultures were obtained, and histologic review was done.

MAIN OUTCOME MEASUREMENTS

Immediate and delayed endoscopic closure of the perforation site, evidence of clinical peritonitis during the 14-day follow-up.

RESULTS

Ten pigs completed the protocol and survived without clinical peritonitis during the 14-day follow-up. Endoscopic closure of a 15-mm esophageal perforation failed, thus, no attempt was made to close a 20-mm esophageal perforation. Closure of all other perforations was successful. At necropsy, fibrinous peritonitis was suspected in one animal with a 10-mm duodenal perforation. Chronic inflammation and fibroplasia at the perforation sites were the most common histologic findings.

LIMITATIONS

The applicability of widespread use in humans remains unknown despite successful case reports in the medical literature.

CONCLUSION

EBL can be used successfully to close 10 to 20 mm perforations within normal stomach, duodenum, and colon and can prevent clinically relevant intra-abdominal infections. However, for esophageal perforations, closure may be limited to small (≤10 mm), iatrogenic perforations.

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.

Infection during natural orifice transluminal endoscopic surgery peritoneoscopy: a randomized comparative study in a survival porcine model

BACKGROUND

Infection in natural orifice transluminal endoscopic surgery (NOTES) remains controversial.

OBJECTIVE

To estimate the frequency of infection during NOTES peritoneoscopy with different routes of access and to compare with laparoscopy.

DESIGN

Prospective randomized controlled study (Canadian Classification type I).

METHODS

Forty female pigs were randomly assigned to 3 NOTES (transgastric, transrectal, and transvaginal) and laparoscopic groups. Antiseptic technique was used for NOTES, whereas laparoscopy was performed in a sterile environment. Preoperative and postoperative intravenous antibiotics were administered. Closure of the transluminal access site was performed in all animals. Peritoneal fluid was collected for culture at the end of surgery and at necropsy at day 14.

RESULTS

Thirty-nine peritoneoscopies were successfully completed. Necropsy confirmed complete healing of NOTES incisions, but 2 animals in the laparoscopy group had small abscesses in the abdominal incisions. There were no statistical differences in the presence of peritoneal adhesions. Positive culture results were seen in all groups at the end of the procedure and in all animals at necropsy, but this did not lead to clinical signs of gross infection. The most common organisms that colonized the peritoneum were gram-positive cocci and gram-negative bacilli from the normal swine gastrointestinal flora.

LIMITATIONS

Animal model and small sample size.

CONCLUSIONS

In these small series of animals and with the careful lavage and preparation used, NOTES appeared to be comparable to laparoscopy in terms of peritoneal contamination and clinical infection. Despite the adherence to a strict antiseptic protocol, peritoneal contamination occurs but does not lead to septic complications in the swine.

Gastric emptying is delayed in transgastric NOTES: a randomized study in swine

AIM

The aim of this study was to evaluate the restoration of gastrointestinal motility after NOTES using capsule endoscopy (CE).

MATERIALS AND METHODS

Twenty adult Yorkshire pigs were randomly assigned to four groups: transgastric NOTES (gNOTES), transrectal NOTES (rNOTES), transvaginal NOTES (vNOTES), and laparoscopy (LAP). At the end of a 30-min peritoneoscopy with identification of seven predetermined organs, an array of eight receivers and the recorder were attached to the abdominal wall. The CE was delivered into the antrum with the help of an endoscope and a polypectomy snare. Animals were kept alive for 14 d.

RESULTS

Median time for surgery was longer in gNOTES (56 min, range 47-63) and vNOTES (54 min, range 44-79) than in LAP (32 min, range 32-33; P < 0.05 and P < 0.01) and in rNOTES (45.5 min, range 33-56) (P = ns). This increase was related to a larger incision and longer closure times. Images from the CE were successfully retrieved in 19 cases. The CE was retained in the stomach in all animals in gNOTES (459 min; range 360-600), but only in one animal in rNOTES and vNOTES and in none in the LAP group. Failure of passage of the CE beyond the stomach was associated with gNOTES and longer closure of the incision. Animals in the gNOTES group gained less weight than the others and this change was statistical significant when compared with vNOTES animals (1.7 kg, range -1.98 to 4.5 versus 8.4 kg, range 5.8 to 11.45; P < 0.01).

CONCLUSION

Gastric emptying is delayed after gNOTES peritoneoscopy compared with rNOTES, vNOTES, and LAP and this effect is associated with less weight gain.