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Zhang Y, Meng Q, Zhou XB, Chen G, Zhu LH, Mao XL, Ye LP. Feasibility of endoscopic resection without laparoscopic assistance for giant gastric subepithelial tumors originating from the muscularis propria layer (with video). Surg Endosc 2022; 36:3619-3628. [DOI: 10.1007/s00464-022-09019-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Accepted: 01/03/2022] [Indexed: 12/15/2022]
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2
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Gastrointestinal exposed endoscopic full-thickness resection in the era of endoscopic suturing: a retrospective single-center case series. Wideochir Inne Tech Maloinwazyjne 2021; 16:321-328. [PMID: 34136027 PMCID: PMC8193753 DOI: 10.5114/wiitm.2021.104496] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 10/26/2020] [Indexed: 12/24/2022] Open
Abstract
Introduction Exposed endoscopic full thickness resection (EFTR) is a minimally invasive technique that has shown promising efficacy and safety in the removal of both gastrointestinal (GI) submucosal tumors (SMTs) arising from the muscularis propria (MP) and select epithelial tumors (ETs) unsuitable for conventional resection techniques. Given the chance of realizing endosurgical full-thickness suturing, the Endoscopic Suturing System (ESS) can be used to close wall defects in this setting. However, data concerning its use in EFTR are still limited. Aim This study was conducted to evaluate the safety and efficacy of exposed EFTR with defect closure using the ESS for the removal of both GI SMTs and select ETs unsuitable for conventional resection techniques. Material and methods This was a retrospective, single-center, observational cohort study of patients who underwent GI exposed EFTR. Results Seven patients (M : F 6 : 1) with a mean age of 56 ±14.5 years were identified. The indications were MP-originating SMTs of the stomach (n = 2) and duodenum (n = 2), and from submucosa of the rectum (n = 1), and 2 ETs of the rectum. Exposed EFTR and defect closure were successfully performed in 6/7 patients. One case was converted to laparoscopic gastric wedge resection due to technical unfeasibility. We performed an R0 resection in all cases, with the exception of 1 case of rectal EFTR. No macroscopic recurrence was detected at 6-month endoscopic follow-up. Conclusions GI exposed EFTR with defect closure by the ESS appears to be feasible, effective, and safe in referral centers. Further studies are necessary to clarify the role of the ESS for post-EFTR wall defect closure.
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Abstract
Gastroduodenal perforation may be spontaneous or traumatic and the majority of spontaneous perforation is due to peptic ulcer disease. Improved medical management of peptic ulceration has reduced the incidence of perforation, but still remains a common cause of peritonitis. The classic sub-diaphragmatic air on chest x-ray may be absent and computed tomography scan is a more sensitive investigation in the stable patient. The management of perforated peptic ulcer disease is still a subject of debate. The majority of perforated peptic ulcers are caused by Helicobacter pylori, so definitive surgery is not usually required. Perforated peptic ulcer is an indication for operation in nearly all cases except when the patient is asymptomatic or unfit for surgery. However, non-operative management has a significant incidence of intra-abdominal abscesses and sepsis. Primary closure is achievable in traumatic perforation, but the management follows the Advanced Trauma Life Support (ATLS) principles.
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Affiliation(s)
- Elroy Patrick Weledji
- Department of Surgery, Faculty of Health Sciences, University of Buea, Buea, Cameroon
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Sachdev AH, Iqbal S, Ribeiro IB, de Moura DTH. Use of omental patch and endoscopic closure technique as an alternative to surgery after endoscopic full thickness resection of gastric intestinal stromal tumors: A series of cases. World J Clin Cases 2020; 8:120-125. [PMID: 31970177 PMCID: PMC6962076 DOI: 10.12998/wjcc.v8.i1.120] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 11/26/2019] [Accepted: 12/13/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Gastrointestinal stromal tumors (GISTs) originate from interstitial cells of Cajal. GISTs can occur anywhere along the gastrointestinal tract. Large lesions have traditionally been removed surgically. However, with recent innovations in advanced endoscopy, GISTs located within the stomach are now removed endoscopically. We describe a new innovative endoscopic technique to close large and hard to access defects after endoscopic full-thickness resection of gastric GISTs.
CASE SUMMARY We present a series of three patients who were diagnosed with a gastric GIST. All patients underwent full-thickness endoscopic resection. In all cases, for closure of the surgical bed, conventional endoscopic techniques including hemoclips, endoloop and suturing were unsuccessful. We performed a new technique in which we pulled omental fat into the gastric lumen and completely closed the defect using endoscopic devices. All patients performed well post-procedure and computed tomography was carried out one day after the procedures which showed no extravasation of contrast.
CONCLUSION The omental plug technique may be used as an alternative to surgery in selected cases of gastric perforation.
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Affiliation(s)
- Amit H Sachdev
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, United States
| | | | - Igor Braga Ribeiro
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-000, Brazil
| | - Diogo Turiani Hourneaux de Moura
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02115, United States
- Gastrointestinal Endoscopy Unit, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo 05403-000, Brazil
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Abstract
With the development of reliable endoscopic closure techniques and tools, endoscopic full-thickness resection (EFTR) is emerging as a therapeutic option for the treatment of subepithelial tumors and epithelial neoplasia with significant fibrosis. EFTR may be categorized as "exposed" and "nonexposed." In exposed EFTR, the full-thickness resection is undertaken with a tunneled or nontunneled technique, with subsequent closure of the defect. In nonexposed EFTR, a secure serosa-to-serosa apposition is achieved before full-thickness resection of the isolated lesion. This document reviews current techniques and devices used for EFTR and reviews clinical applications and outcomes.
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Key Words
- EFTR, endoscopic full-thickness resection
- ESD, endoscopic submucosal dissection
- GIST, GI stromal tumor
- NOTES, natural orifice transluminal endoscopic surgery
- OTSC, over-the-scope clip
- POEM, per-oral endoscopic myotomy
- PTFE, polytetrafluoroethylene
- SET, subepithelial tumor
- STER, submucosal tunnel endoscopic resection
- TTS, through-the-scope
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Duan TY, Tan YY, Wang XH, Lv L, Liu DL. A comparison of submucosal tunneling endoscopic resection and endoscopic full-thickness resection for gastric fundus submucosal tumors. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2018; 110:160-165. [PMID: 29284271 DOI: 10.17235/reed.2017.4699/2016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
AIM Both submucosal tunneling endoscopic resection (STER) and endoscopic full-thickness resection (EFTR) are effective methods for gastric fundus submucosal tumors (SMTs). However, there is little data that compares the two methods. The aim of this study was to compare the safety and efficacy of STER and EFTR for the treatment of SMTs in the gastric fundus. METHODS Clinical data was retrospectively collected from patients with gastric fundus SMTs who underwent STER or EFTR at our hospital from April 2011 to May 2016. Epidemiological data (gender, age), tumor size, procedure-related parameters, complications, postoperative hospital stay, cost and follow-up data were compared. RESULTS A total of 43 patients were enrolled: 15 underwent STER and the remaining 28 cases underwent EFTR. There were no significant differences between the two groups with regard to gender, age, tumor size, en bloc resection rate, operation time, pathohistological results and cost (p > 0.05). However, patients who underwent EFTR had a longer suture time, required a larger number of clips for closure and a prolonged postoperative hospital stay (p < 0.05). No recurrence was noted in either the STER or the EFTR group during a mean follow-up of 12.1 and 22.8 months, respectively. CONCLUSIONS The treatment efficacy of STER and EFTR for the treatment of gastric fundus SMTs was comparable. However, STER has some advantages over EFTR in terms of suture time, the number of clips required for closure and postoperative hospital stay.
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Affiliation(s)
- Tian-Ying Duan
- Department of Gastroenterology, the Second Xiangya Hospital of Central South University
| | - Yu-Yong Tan
- Department of Gastroenterology, the Second Xiangya Hospital of Central South University
| | - Xue-Hong Wang
- Department of Gastroenterology, the Second Xiangya Hospital of Central South University
| | - Liang Lv
- Department of Gastroenterology, the Second Xiangya Hospital of Central South University
| | - De-Liang Liu
- Gastroenterology, the Second Xiangya Hospital, China
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Chung KT, Shelat VG. Perforated peptic ulcer - an update. World J Gastrointest Surg 2017; 9:1-12. [PMID: 28138363 PMCID: PMC5237817 DOI: 10.4240/wjgs.v9.i1.1] [Citation(s) in RCA: 112] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 11/04/2016] [Accepted: 11/29/2016] [Indexed: 02/06/2023] Open
Abstract
Peptic ulcer disease (PUD) affects 4 million people worldwide annually. The incidence of PUD has been estimated at around 1.5% to 3%. Perforated peptic ulcer (PPU) is a serious complication of PUD and patients with PPU often present with acute abdomen that carries high risk for morbidity and mortality. The lifetime prevalence of perforation in patients with PUD is about 5%. PPU carries a mortality ranging from 1.3% to 20%. Thirty-day mortality rate reaching 20% and 90-d mortality rate of up to 30% have been reported. In this review we have summarized the current evidence on PPU to update readers. This literature review includes the most updated information such as common causes, clinical features, diagnostic methods, non-operative and operative management, post-operative complications and different scoring systems of PPU. With the advancement of medical technology, PUD can now be treated with medications instead of elective surgery. The classic triad of sudden onset of abdominal pain, tachycardia and abdominal rigidity is the hallmark of PPU. Erect chest radiograph may miss 15% of cases with air under the diaphragm in patients with bowel perforation. Early diagnosis, prompt resuscitation and urgent surgical intervention are essential to improve outcomes. Exploratory laparotomy and omental patch repair remains the gold standard. Laparoscopic surgery should be considered when expertise is available. Gastrectomy is recommended in patients with large or malignant ulcer.
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Cai M, Zhou P, Lourenço LC, Zhang D. Endoscopic Full-thickness Resection (EFTR) for Gastrointestinal Subepithelial Tumors. Gastrointest Endosc Clin N Am 2016; 26:283-295. [PMID: 27036898 DOI: 10.1016/j.giec.2015.12.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
There has been booming interest in the endoscopic full-thickness resection (EFTR) technique since it was first described. With the advent of improved and more secure endoscopic closure techniques and devices, such as endoscopic suturing devices, endoscopists are empowered to perform more aggressive procedures than ever. This article focuses on the procedural technique and clinical outcomes of EFTR for gastrointestinal subepithelial tumors.
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Affiliation(s)
- Mingyan Cai
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai 20032, China
| | - Pinghong Zhou
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai 20032, China.
| | - Luís Carvalho Lourenço
- Gastroenterology Department, Hospital Professor Doutor Fernando Fonseca, IC-19, Venteira, Amadora 2720276, Portugal
| | - Danfeng Zhang
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai 20032, China
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Stavropoulos SN, Modayil R, Friedel D. Closing perforations and postperforation management in endoscopy: esophagus and stomach. Gastrointest Endosc Clin N Am 2015; 25:29-45. [PMID: 25442956 DOI: 10.1016/j.giec.2014.09.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Luminal perforation after endoscopy is a dreaded complication that is associated with significant morbidity and mortality, longer and more costly hospitalization, and the specter of potential future litigation. The management of such perforations requires a multidisciplinary approach. Until recently, surgery was required. However, nowadays the endoscopist has a burgeoning armamentarium of devices and techniques that may obviate surgery. This article discusses the approach to endoscopic perforations in the esophagus and stomach.
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Affiliation(s)
- Stavros N Stavropoulos
- Department of Gastroenterology, Hepatology and Nutrition, Winthrop University Hospital, 222 Station Plaza North, Suite 429, Mineola, NY 11501, USA.
| | - Rani Modayil
- Department of Gastroenterology, Hepatology and Nutrition, Winthrop University Hospital, 222 Station Plaza North, Suite 429, Mineola, NY 11501, USA
| | - David Friedel
- Department of Gastroenterology, Hepatology and Nutrition, Winthrop University Hospital, 222 Station Plaza North, Suite 429, Mineola, NY 11501, USA
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Law R, Deters JL, Miller CA, Marler RJ, Baron TH. Endoscopic band ligation for closure of GI perforations in a porcine animal model (with video). Gastrointest Endosc 2014; 80:717-722. [PMID: 25085337 DOI: 10.1016/j.gie.2014.06.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2014] [Accepted: 06/03/2014] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Ryan Law
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jodie L Deters
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Charles A Miller
- Division of Gastroenterology & Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ronald J Marler
- Department of Comparative Medicine, Mayo Clinic, Scottsdale, Arizona, USA
| | - Todd H Baron
- Division of Gastroenterology & Hepatology, University of North Carolina, Chapel Hill, North Carolina, USA
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11
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Diagnosis and treatment of perforated or bleeding peptic ulcers: 2013 WSES position paper. World J Emerg Surg 2014; 9:45. [PMID: 25114715 PMCID: PMC4127969 DOI: 10.1186/1749-7922-9-45] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 06/26/2014] [Indexed: 12/11/2022] Open
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12
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Di Saverio S, Bassi M, Smerieri N, Masetti M, Ferrara F, Fabbri C, Ansaloni L, Ghersi S, Serenari M, Coccolini F, Naidoo N, Sartelli M, Tugnoli G, Catena F, Cennamo V, Jovine E. Diagnosis and treatment of perforated or bleeding peptic ulcers: 2013 WSES position paper. World J Emerg Surg 2014. [PMID: 25114715 DOI: 10.1186/1749-7922-9-451749] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Salomone Di Saverio
- Emergency and General Surgery Dept, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| | - Marco Bassi
- Department of Gastroenterology and Operative Endoscopy, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| | - Nazareno Smerieri
- Emergency and General Surgery Dept, Maggiore Hospital- Bologna Local Health District, Bologna, Italy.,Liver and Multivisceral Transplantation Unit, University of Modena&Reggio Emilia - Policlinico Hospital, Modena, Italy
| | - Michele Masetti
- Emergency and General Surgery Dept, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| | - Francesco Ferrara
- Department of Gastroenterology and Operative Endoscopy, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| | - Carlo Fabbri
- Department of Gastroenterology and Operative Endoscopy, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| | - Luca Ansaloni
- General and Emergency and Trauma Surgery, I unit, Ospedali Riuniti, Bergamo, Italy
| | - Stefania Ghersi
- Department of Gastroenterology and Operative Endoscopy, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| | - Matteo Serenari
- Emergency and General Surgery Dept, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| | - Federico Coccolini
- General and Emergency and Trauma Surgery, I unit, Ospedali Riuniti, Bergamo, Italy
| | - Noel Naidoo
- Port Shepstone Regional Hospital, Port Shepstone, South Africa - Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa
| | | | - Gregorio Tugnoli
- Emergency and General Surgery Dept, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| | - Fausto Catena
- Emergency and Trauma Surgery Dept., Maggiore Hospital of Parma, Parma, Italy
| | - Vincenzo Cennamo
- Department of Gastroenterology and Operative Endoscopy, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
| | - Elio Jovine
- Emergency and General Surgery Dept, Maggiore Hospital- Bologna Local Health District, Bologna, Italy
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Raju GS. Endoscopic clip closure of gastrointestinal perforations, fistulae, and leaks. Dig Endosc 2014; 26 Suppl 1:95-104. [PMID: 24373001 DOI: 10.1111/den.12191] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 09/17/2013] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Gottumukkala S Raju
- Department of Gastroenterology, Hepatology, and Nutrition, University of Texas MD Anderson Cancer Center, Houston, USA
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Sun G, Yang Y, Zhang X, Li W, Wang Y, Zhang L, Tang P, Kong J, Zhang R, Meng J, Wang X. Comparison of gastrotomy closure modalities for natural orifice transluminal surgery: a canine study. Gastrointest Endosc 2013; 77:774-83. [PMID: 23453129 DOI: 10.1016/j.gie.2012.12.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Accepted: 12/17/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND Reliable closure of the gastrotomy after transgastric natural orifice transluminal endoscopic surgery (NOTES) remains unresolved. OBJECTIVE To compare the technical aspects and clinical and histologic outcomes of NOTES gastrotomy closure techniques. DESIGN Experimental study. SETTING Animal laboratory. PATIENTS Thirty-four dogs, 14 for nonsurvival study and 20 for survival study. INTERVENTIONS The animals randomly received different gastrotomy closures after NOTES: endoclip, omentoplasty, over-the-scope-clip (OTSC), and hand-suturing. MAIN OUTCOME MEASUREMENTS Procedure time, closure strength, survival, postoperative adverse events, and histologic evaluation of wound healing. RESULTS Omentoplasty and OTSC groups needed shorter procedure times and fewer clips than the endoclip group. The endoclip and omentoplasty groups generated similar leakage pressures (34.5 ± 2.6 vs 42.2 ± 4.1 mm Hg, P > .05), both lower than OTSC and hand-suturing groups (81.5 ± 2.1 and 87.0 ± 3.0 mm Hg, respectively, P < .001). Of the 20 animals in the survival study (all 4 groups), only 2 of 6 in the endoclip group were killed prematurely due to sepsis. Necropsy revealed the OTSC group reached a 100% clip retention rate, higher than the endoclip (47.9%) and omentoplasty groups (44.4%, P < .05) rates. Complete healing, defined as intact and continuous gastric layers microscopically, was seen in 83.3% of animals (5 of 6) in the omentoplasty group, comparable with OTSC (4 of 6, 66.7%, P = .500) but higher than the endoclip group (1 of 6, 16.7%, P = .04). LIMITATIONS Animal study. CONCLUSIONS Omentoplasty is easier and safer for NOTES gastrotomy closure than endoclips and offers safety profile and efficacy similar to OTSC and hand-suturing.
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Affiliation(s)
- Gang Sun
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China
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Kim JH, Ahn HD, Kwon KA, Kim YJ, Chung JW, Park DK, Kim JH. Spontaneous healing of gastric perforation after endoscopic ligation for gastric varices. J Korean Med Sci 2013; 28:624-7. [PMID: 23579928 PMCID: PMC3617319 DOI: 10.3346/jkms.2013.28.4.624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Accepted: 01/11/2013] [Indexed: 11/30/2022] Open
Abstract
Endoscopic variceal ligation (EVL) can be performed as an optional therapy for gastric variceal bleeding if endoscopic sclerotherapy (ES) is not readily available or if practitioners lack experience. EVL using an endoscopic pneumo-activated ligating device was performed on a 53-year-old male patient with liver cirrhosis who presented with hematemesis. Follow-up esophagogastroduodenoscopy (EGD) performed two days after the EVL showed gastric perforation at the EVL-procedure site on the gastric fundus. However, the patient refused emergency surgery, and therefore received only supportive management, including intravenous antibiotics. EGD 10 days later showed healing of the perforation site. This is the first report of a case of gastric variceal bleeding with development of a gastric perforation soon after EVL, which showed complete recovery with conservative therapy and without surgical intervention.
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Affiliation(s)
- Jung Ho Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Hong Dae Ahn
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Kwang An Kwon
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Yoon Jae Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Jun-Won Chung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Dong Kyun Park
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Ju Hyun Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
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Feasibility of NOTES omental plug repair of perforated peptic ulcers: results from a clinical pilot trial. Surg Endosc 2013; 27:2201-8. [PMID: 23355151 DOI: 10.1007/s00464-012-2740-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2012] [Accepted: 12/04/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND Ulcer perforation carries up to a 30 % 1-year mortality rate. Intervention-related adverse events are among statistically significant predictors of 1-year mortality. A natural orifice transluminal endoscopic surgical (NOTES) approach may be less invasive and may decrease procedure-related adverse events by diminishing the so-called second hit, thus leading to decreased morbidity and mortality. We sought to assess the feasibility of an endoscopic transluminal omental plug technique in patients with perforated gastroduodenal ulcers under laparoscopic guidance. METHODS Patients with suspected acute gastroduodenal ulcer perforations were offered participation in this prospective pilot study. Closure of the perforation was attempted using the NOTES omental plug technique. Demographic, clinical, endoscopic, and radiographic data were abstracted, as were data for morbidity, mortality, and pilot data regarding quality of life (QOL). RESULTS From February 2010 through February 2012, a total of 17 patients presented to a tertiary care center with clinically suspected perforated ulcer. Of seven patients (mean age 79 years, range 64-89 years) who consented to the study, three underwent the study procedure. All patients had multiple comorbidities. Two patients presented with 4-6 mm perforated peptic ulcers and underwent successful laparoscopic-assisted NOTES omental and falciform ligament patch closure, respectively. Postoperative radiographic contrast studies showed no leak, and patients were discharged home on postoperative days 3 and 4. The third patient had undergone enterocutaneous fistula repair with herniorrhaphy 6 weeks before. Although a transluminal endoscopic approach was feasible, the omentum was under too much tension to be secured. This procedure was converted to an open omental patch repair. For all but one patient who provided consent, obtaining QOL data was feasible. CONCLUSIONS Initial results from a laparoscopic-assisted NOTES approach for closure of perforated peptic ulcers appear promising and enable swift recovery in selected patients. This is especially important in elderly and/or immunocompromised patients. Technical details and patient selection criteria continue to evolve.
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Kim YJ, Shin SK, Lee HJ, Chung HS, Lee YC, Park JC, Hyung WJ, Noh SH, Kim CB, Lee SK. Endoscopic management of anastomotic leakage after gastrectomy for gastric cancer: how efficacious is it? Scand J Gastroenterol 2013; 48:111-8. [PMID: 23116156 DOI: 10.3109/00365521.2012.737362] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Anastomotic leak is a dreadful complication with a high mortality rate. The authors aimed to evaluate the efficacy of endoscopic closure of anastomotic dehiscence after gastrectomy in patients with gastric cancer. METHODS The authors retrospectively reviewed 33 patients with anastomotic leakage who had underdone endoscopic treatment among 5249 patients with gastric cancer who underwent radical total or subtotal gastrectomy. Methods of endoscopic closure included clipping with or without detachable snare, fibrosealant, Histoacryl® or stent insertion. Results of endoscopic treatment were categorized as complete, partial closure and failure. RESULTS The size of the tissue defect was the only factor that had statistically significant differences among the cases with complete closure, partial closure and failure (p = 0.005). For tissue defects smaller than 2 cm in size, complete closure was achieved in 19 (73.1%), partial closure in 5 patients (19.2%) and 2 failed (7.6%). For those larger than 2 cm in size, one (14.3%) was completely closed, four (57.1%) were partially closed and two (28.6%) failed. CONCLUSIONS Endoscopic treatment for anastomotic dehiscence smaller than 2 cm in size had excellent success rate in this study.
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Affiliation(s)
- Yu Jin Kim
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, South Korea
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Abstract
PURPOSE OF REVIEW Understanding the role of endoscopic closure techniques helps in expanding the endoscopist's role in the management of gastrointestinal neoplasia and explore new frontiers of minimally invasive endoluminal surgery. RECENT FINDINGS This article covers recent advances in endoscopic closure of various gastrointestinal perforations, with a special focus on devices, experimental evidence and clinical outcomes of endoscopic closure of gastrointestinal perforations. SUMMARY Endoscopic closure techniques help the endoscopist to walk on thin ice and save himself and the patient in the case of mishap.
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Chukwumah C, Zorron R, Marks JM, Ponsky JL. Current Status of Natural Orifice Translumenal Endoscopic Surgery (NOTES). Curr Probl Surg 2010; 47:630-68. [DOI: 10.1067/j.cpsurg.2010.04.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Moran EA, Gostout CJ, McConico AL, Bingener J. Natural orifice translumenal endoscopic surgery used for perforated viscus repair is feasible using lower peritoneal pressures than laparoscopy in a porcine model. J Am Coll Surg 2010; 210:474-9. [PMID: 20347740 DOI: 10.1016/j.jamcollsurg.2009.11.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2009] [Revised: 11/20/2009] [Accepted: 11/24/2009] [Indexed: 01/08/2023]
Abstract
BACKGROUND Procedure-related complications contribute to 1-year mortality in patients with perforated ulcers. Natural orifice translumenal endoscopic surgery (NOTES) might offer a new repair approach. STUDY DESIGN Swine were randomized to laparoscopic or NOTES repair. Laparoscopic gastrotomy creation (1 cm) was followed by 4 hours soilage time. After peritoneal cavity irrigation (per group assignment), repair proceeded with a laparoscopic or NOTES approach. For NOTES repair, omentum was endoscopically grasped, pulled into the gastric lumen, and fixed with metallic clips. Feasibility; time to complete procedures; pneumoperitoneal pressures; and clinical parameters, including necropsy and peritoneal culture at 2 weeks, were recorded. RESULTS NOTES repair failed in 1 animal (technical); repair was completed laparoscopically, and data were analyzed as intention to treat. Specific NOTES repair time (minutes) was comparable with laparoscopy (36 versus 46; p = 0.2). Mean abdominal pressure (mmHg) required to complete NOTES repair was lower than in laparoscopy (4 versus 12; p < 0.001). Nineteen of 23 animals thrived until necropsy at 2 weeks. Three animals succumbed to airway compromise in recovery; 1 NOTES animal failed to thrive on postoperative day 7. No intra-abdominal cause for these deaths was found. At necropsy all repairs were intact, and peritoneal cultures revealed a small and equivalent amount of colony-forming units in each group. CONCLUSIONS Endoscopic ulcer repair appears technically feasible with similar clinical and infectious outcomes to laparoscopy. The lower required pneumoperitoneal pressures used in these NOTES techniques are recognizable different outcomes from laparoscopy and can be advantageous in critically ill patients.
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Affiliation(s)
- Erica A Moran
- Department of Surgery, Mayo Clinic, Rochester, MN 55905, USA
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Madan AK, Martinez JM, Menzo EL, Khan KA, Tichansky DS. Omental Reinforcement for Intraoperative Leak Repairs during Laparoscopic Roux-en-Y Gastric Bypass. Am Surg 2009. [DOI: 10.1177/000313480907500917] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Leaks from the gastrojejunostomy after laparoscopic Roux-en-Y gastric bypass (LRYGB) have the potential for significant morbidity and mortality. When intraoperative leaks are discovered, we choose to perform omental reinforcement around the gastrojejunostomy and pouch after suture repair of the leaks. This study examined the hypothesis that omental reinforcement would be useful after intraoperative leaks during LRYGB. Omental reinforcement was performed on gastrojejunostomies, in which leaks were seen, created using a circular stapler during LRYGB. Data were reviewed retrospectively on these patients. There were a total of 387 patients with 32 (8.26%) patients who had a staple line dehiscence or evidence of gastric pouch or gastrojejunostomy leak intraoperatively Leaks/dehiscences were repaired with sutures and then reinforced with omentum. None of these patient developed anastomotic leak postoperatively. Of the other 365 patients, there were four (1.1%) leaks from the gastrojejunostomy and/or gastric pouch. Omental reinforcement may be useful in decreasing the incidence of postoperative leaks when an intraoperative leak is encountered during LRYGB. However, omental reinforcement does not completely prevent a postoperative leak. Consideration of reinforcement with omentum may be given for patients in whom an intraoperative leak is noted.
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Affiliation(s)
- Atul K. Madan
- Division of Laparoendoscopic and Bariatric Surgery, University of Miami, Miami, Florida
| | - Jose M. Martinez
- Division of Laparoendoscopic and Bariatric Surgery, University of Miami, Miami, Florida
| | - Emanuele Lo Menzo
- Division of Laparoendoscopic and Bariatric Surgery, University of Miami, Miami, Florida
| | - Khurram A. Khan
- Colorado Springs Health Partners, PC, Colorado Springs, Colorado
| | - David S. Tichansky
- Division of Minimally Invasive and Bariatric Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
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Dray X, Giday SA, Buscaglia JM, Gabrielson KL, Kantsevoy SV, Magno P, Assumpcao L, Shin EJ, Reddings SK, Woods KE, Marohn MR, Kalloo AN. Omentoplasty for gastrotomy closure after natural orifice transluminal endoscopic surgery procedures (with video). Gastrointest Endosc 2009; 70:131-40. [PMID: 19394007 DOI: 10.1016/j.gie.2008.10.035] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2008] [Accepted: 10/14/2008] [Indexed: 12/16/2022]
Abstract
INTRODUCTION The utility of the greater omentum has not been assessed in transluminal access closure after natural orifice transluminal endoscopic surgery (NOTES) procedures. OBJECTIVE Our purpose was to evaluate the feasibility, efficacy, and safety of omentoplasty for gastrotomy closure. METHODS AND PROCEDURES Survival experiments in 9 female 40-kg pigs were randomly assigned to 3 groups: group A, endoscopic full-thickness resection (EFTR) for transgastric access and peritoneoscopy without closure; group B, ETFR and peritoneoscopy with omentoplasty (flap of omentum is pulled into the stomach and attached to the gastric mucosa with clips but no clips are used for gastrotomy closure itself); group C, balloon dilation for opening and peritoneoscopy followed by omentoplasty for closure. The animals were observed for 2 weeks and then underwent endoscopy and necropsy with histologic evaluation. RESULTS Transgastric opening and peritoneoscopy were achieved in all pigs. In groups B and C, a flap of omentum was easily placed to seal the gastrotomy and then attached to the gastric mucosa with 2 to 5 clips (median 4) in 7 to 20 minutes (median 15 minutes). In group A, peritonitis developed in all animals. In both groups B and C, all animals survived 15 days with no peritonitis and minimal adhesions outside the gastrotomy site. In addition, all achieved complete healing (transmural, n = 4; mucosal ulceration, n = 2) of the gastrotomy site. One animal in group B had an 18-mm abscess in the omental flap. LIMITATIONS Animal model, small sample size, lack of appropriate controls for group C. CONCLUSIONS Omentoplasty of the gastrotomy site is a technically feasible method to seal balloon-created transgastric access to the peritoneal cavity after NOTES procedures.
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Affiliation(s)
- Xavier Dray
- Division of Gastroenterology and Hepatology, Johns Hopkins School of Medicine, Baltimore, Maryland 21205, USA.
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Abstract
Surgery has been the mainstay of therapy in patients with gastrointestinal perforations. This paradigm started to shift with the development of techniques for endoscopic closure of gastrointestinal perforations. A detailed review of the literature on this subject, along with a commentary on practical aspects in the management of patients with gastrointestinal leaks, is provided here.
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Peroral transgastric endoscopic procedures in pigs: feasibility, survival, questionings, and pitfalls. Surg Endosc 2008; 23:394-402. [DOI: 10.1007/s00464-008-9930-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2007] [Accepted: 02/24/2008] [Indexed: 11/25/2022]
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Cios TJ, Reavis KM, Renton DR, Hazey JW, Mikami DJ, Narula VK, Allemang MT, Davis SS, Melvin WS. Gastrotomy closure using bioabsorbable plugs in a canine model. Surg Endosc 2007; 22:961-6. [PMID: 17710490 DOI: 10.1007/s00464-007-9530-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2007] [Revised: 06/27/2007] [Accepted: 07/07/2007] [Indexed: 10/22/2022]
Abstract
The repair of gastric perforation commonly involves simple suture closure using an open or laparoscopic approach. An endolumenal approach using prosthetic materials may be beneficial. The role of bioprosthetics in this instance has not been thoroughly investigated, thus the authors evaluated the feasibility of gastric perforation repair using a bioabsorbable device and quantified gross and histological changes at the injury site. Twelve canines were anesthetized and underwent open gastrotomy. A 1-cm-diameter perforation was created in the anterior wall of the stomach and plugged with a bioabsorbable device. Intralumenal pH was recorded. Canines were sacrificed at one, four, six, eight, and 12 weeks. The stomach was explanted followed by gross and histological examination. The injury site was examined. The relative ability of the device to seal the perforation was recorded, as were postoperative changes. Tissue samples were analyzed for gross and microscopic tissue growth and compared to normal gastric tissue in the same animal as an internal control. A scoring system of -2 to +2 was used to measure injury site healing (-2= leak, -1= no leak and minimal ingrowth, 0= physiologic healing, +1= mild hypertrophic tissue, +2= severe hypertrophic tissue). In all canines, the bioprosthesis successfully sealed the perforation without leak under ex vivo insufflation. At one week, the device maintained its integrity but there was no tissue ingrowth. Histological healing score was -1. At 4-12 weeks, gross examination revealed a healed injury site in all animals. The lumenal portion of the plug was completely absorbed. The gross and histological healing score ranged from -1 to +1. The application of a bioabsorbable device results in durable closure of gastric perforation with physiologic healing of the injury site. This method of gastrotomy closure may aid in the evolution of advanced endoscopic approaches to perforation closure of hollow viscera.
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Abstract
Endoscopic closure of gastrointestinal perforations, fistulas, and anastomotic dehiscence is technically feasible. Endoluminal closure of the instrumental perforations of the gastrointestinal tract can be accomplished immediately after the recognition of perforation, while avoiding the delay of arranging surgery and the trauma associated with thoracotomy or laparotomy. In addition, endoscopic closure should be considered in patients with anastomotic dehiscence and chronic fistulas as this may avoid the risk associated with reoperation. The outcome of closure depends on the technical expertise in the proper selection and use of various endoluminal closure options. Training of the endoscopists in the use of this novel technology will enhance the quality of care of our patients.
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Affiliation(s)
- G S Raju
- Center for Endoscopic Research, Training, and Innovation (CERTAIN), Department of Internal Medicine, 4.106 McCullough Building, 301 University Boulevard, University of Texas Medical Branch, Galveston, TX 77555-0764, USA.
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Sumiyama K, Gostout CJ, Rajan E, Bakken TA, Deters JL, Knipschield MA. Endoscopic full-thickness closure of large gastric perforations by use of tissue anchors. Gastrointest Endosc 2007; 65:134-9. [PMID: 17185093 DOI: 10.1016/j.gie.2006.01.050] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2005] [Accepted: 01/15/2006] [Indexed: 02/06/2023]
Abstract
BACKGROUND A flexible needle-catheter tissue-anchoring device was developed to accomplish full-thickness tissue apposition of the GI wall. The aim of this study was to identify the performance of this device for repair of large iatrogenic gastric perforations in a porcine model. OBJECTIVES Six pigs. DESIGN Short-term survival animal study. SETTINGS Pigs were studied while they were under general anesthesia. Device performance in differing gastric locations and wall thicknesses was assessed by 2 perforations more than 2 cm in size created for each pig along the greater curvature and the anterior wall. INTERVENTIONS Each perforation was closed by parallel placement of tissue anchor sets sequentially along the length of the perforation. MAIN OUTCOME MEASUREMENTS One week follow-up endoscopy and necropsy were performed. RESULTS Twelve perforations were closed with the 48 tissue anchor sets. All animals survived for 1 week without clinical complications. Follow-up endoscopy and necropsy revealed that all tissue anchors remained with firmly held sutures and sealed perforations. CONCLUSIONS Full-thickness closure with a new tissue-anchoring device simply and successfully repaired large iatrogenic gastric perforations.
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Affiliation(s)
- Kazuki Sumiyama
- Developmental Endoscopy Unit, Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA
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Pham BV, Raju GS, Ahmed I, Brining D, Chung S, Cotton P, Gostout CJ, Hawes RH, Kalloo AN, Kantsevoy SV, Pasricha PJ. Immediate endoscopic closure of colon perforation by using a prototype endoscopic suturing device: feasibility and outcome in a porcine model (with video). Gastrointest Endosc 2006; 64:113-9. [PMID: 16813815 DOI: 10.1016/j.gie.2005.11.046] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2005] [Accepted: 11/21/2005] [Indexed: 12/31/2022]
Abstract
BACKGROUND Perforation is an uncommon but potentially devastating complication of colonoscopy. Surgical closure is the standard of care. Immediate endoluminal closure of a perforation would avoid the morbidity and mortality associated with general anesthesia, laparotomy, and surgical repair. OBJECTIVES To evaluate the feasibility and safety of full-thickness endoscopic closure of colonic perforations with a prototype endoscopic suturing device, the Eagle Claw, in a porcine model. DESIGN Endoscopic animal experimental study of closure of colon perforation by using a porcine model. SUBJECTS Ten pigs were included in the study. INTERVENTIONS The Eagle Claw was used to close small perforations (1.5 to 2 cm) of the colon created by needle-knife with the animal under general anesthesia by using the endoluminal route. All animals received intravenous antibiotics and were allowed to eat after 24 hours. MAIN OUTCOME MEASUREMENTS The animals were monitored daily for signs of sepsis and peritonitis. On day 7, they were euthanized. The peritoneal cavity was examined for fecal peritonitis, and the colon perforation site was checked for wound dehiscence and pericolic abscess formation. RESULTS Endoscopic closure of the colon perforation was successful in 7 animals, and they recovered well without any sepsis or peritonitis. Necropsy did not reveal fecal peritonitis or pericolonic abscess formation at the site of perforation, and the perforation healed well. Closure was successful in 1 animal, but necropsy revealed dehiscence of the colon perforation site. Endoscopic closure was unsuccessful in 2 animals, and these were euthanized immediately. CONCLUSIONS Closure of acute perforation of the colon is feasible with the Eagle Claw endoscopic suturing device in a porcine model.
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Affiliation(s)
- Binh V Pham
- Center for Endoscopic Research, Training, and Innovation (CERTAIN), Department of Internal Medicine, University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555, USA
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Seewald S, Soehendra N. Perforation: part and parcel of endoscopic resection? Gastrointest Endosc 2006; 63:602-5. [PMID: 16564859 DOI: 10.1016/j.gie.2005.08.034] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2005] [Accepted: 08/27/2005] [Indexed: 02/08/2023]
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Bertleff MJOE, Liem RSB, Bartels HL, Robinson PH, Van der Werff JFA, Bonjer HJ, Lange JF. The “stamp method”: a new treatment for perforated peptic ulcer? Surg Endosc 2006; 20:791-3. [PMID: 16544084 DOI: 10.1007/s00464-004-2157-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2004] [Accepted: 02/11/2005] [Indexed: 01/15/2023]
Abstract
BACKGROUND The aim of this study was to develop a simple method for closure of a perforated peptic ulcer, making it more accessible for laparoscopic surgery. METHODS An experimental pilot study was performed using five male Wistar rats. The perforation was closed by a bioabsorbable patch made of lactide-glycolid-caprolactone fixed with glue onto the outside of the stomach. RESULTS Postoperatively, there were no signs of leakage or other complications. Histologically, there were no signs of inflammation on the inside of the stomach, and there was a 50% reduction of the perforation each successive postoperative week. No adverse reactions because of the degradable material or glue were observed. CONCLUSIONS Treatment of a perforated peptic ulcer by placing a patch of biodegradable material like a "stamp" on the outside of the stomach is a feasible option.
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Affiliation(s)
- M J O E Bertleff
- Department of Plastic Surgery, Academic hospital Groningen, Hanzeplein 1, P.O. Box 30001, Groningen, 9700 RB, The Netherlands.
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Ikeda K, Fritscher-Ravens A, Mosse CA, Mills T, Tajiri H, Swain CP. Endoscopic full-thickness resection with sutured closure in a porcine model. Gastrointest Endosc 2005; 62:122-9. [PMID: 15990831 DOI: 10.1016/s0016-5107(05)00517-1] [Citation(s) in RCA: 114] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Some early gastric cancers might be advantageously staged and treated by full-thickness resection if secure methods for closing the defect were available. The aim of this study was to test the feasibility of full-thickness gastric resection. METHODS Full-thickness gastric resections were performed by using a ligating device without submucosal injection in survival studies in pigs (n = 8). The defects were closed by using new methods for suturing, locking, and cutting thread through a 2.8-mm accessory channel. Stitches (n = 2-4) were placed close to the target area before resection. OBSERVATIONS Full-thickness resections (n = 8) were performed. The pigs survived without incident for 21 to 28 days. Healing of the suture site was evident at follow-up endoscopy. Suture sites were water tight. The pull-out force with stitches by using this new sewing method was significantly higher than with endoscopic clips (20.3 N +/- 0.94 vs. 2.2 N +/- 0.42, p < 0.05). CONCLUSIONS Endoscopic full-thickness resection with sutured defect closure was feasible and appeared safe in these survival experiments.
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Affiliation(s)
- Keiichi Ikeda
- Department of Endoscopy, The Jikei University School of Medicine, Tokyo, Japan
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Dobrucali A, Baca B. Is metallic clip application reliable for perforations of the stomach caused by EMR? Gastrointest Endosc 2004; 60:669-70; author reply 670-1. [PMID: 15472709 DOI: 10.1016/s0016-5107(04)01873-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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Abstract
Iatrogenic perforation of the gastrointestinal tract is a medical emergency and is inevitable. An endoscopist must maintain a high index of suspicion despite minimal or atypical symptoms and negative radiologic studies, because perforation is a complication with tremendous morbidity and mortality. The endoscopist must know how to manage this complication appropriately and to seek immediate surgical consultation. There is ongoing controversy about when a patient should undergo nonoperative or surgical therapy. An evidence-based approach to manage iatrogenic perforation is not possible. The trend in the modern era is to less invasive, nonoperative therapy, given advancements in ICU care and antibiotics. Laparoscopy or laparoscopic-assisted (minilaparotomy) surgery is also being increasingly used with outcomes comparable with conventional laparotomy. Experience and advancements in accessories have enabled endoscopic repair of iatrogenic perforation in many situations [84]. The management algorithms provided synthesize the pertinent literature into reasonable guidelines to follow. Ultimately, an individualized approach must be taken to manage the patient with an iatrogenic perforation.
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Affiliation(s)
- Rajesh V Putcha
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center at Dallas, Room F.4.310, 5323 Harry Hines Boulevard, Dallas, TX 75390-8887, USA
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Fairbanks KD, Kalloo AN. Therapeutic endoscopic retrograde cholangiopancreatography: what the future holds. Gastrointest Endosc Clin N Am 2003; 13:799-809. [PMID: 14986799 DOI: 10.1016/s1052-5157(03)00073-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
These are exciting times for interventional endoscopists performing ERCP. The advent of noninvasive, diagnostic techniques of the pancreaticobiliary tree has resulted in a shift toward more therapeutic procedures. The combination of major technologic advances together with endoscopists' growing comfort with invasive procedures has helped to push the boundaries of endoscopic therapy. These therapies, however, should always be sanctioned by sound science and well-controlled clinical trials.
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Affiliation(s)
- Kyrsten D Fairbanks
- Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, MD 21205, USA
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Gómez NA, Zapatier JA, Vargas PE. Repair of full-thickness defects in alimentary tract wall with patches of expanded polytetrafluoroethylene. Ann Surg 2003; 238:301; author reply 301-2. [PMID: 12894025 PMCID: PMC1422683 DOI: 10.1097/01.sla.0000085814.82605.ba] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Tsunada S, Ogata S, Ohyama T, Ootani H, Oda K, Kikkawa A, Ootani A, Sakata H, Iwakiri R, Fujimoto K. Endoscopic closure of perforations caused by EMR in the stomach by application of metallic clips. Gastrointest Endosc 2003; 57:948-51. [PMID: 12776053 DOI: 10.1016/s0016-5107(03)70051-0] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The number of complications associated with use of EMR for early-stage gastric cancer, including perforation, has increased with the increasing use of this procedure. Endoscopic clip application was performed in patients who sustained a perforation as a result of EMR for gastric neoplasm. PATIENTS AND METHODS Seven patients who underwent endoscopic application of metallic clips to close perforations were studied. The omental patch method was applied in one case with a large perforation. OBSERVATIONS In all patients, endoscopic clip application successfully closed the perforation of the stomach, which occurred after EMR. No patient required laparotomy. CONCLUSIONS The technique of endoscopic clip application might be useful for treatment of patients who sustain a perforation caused by EMR.
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Affiliation(s)
- Seiji Tsunada
- Department of Internal Medicine and Endoscopy, Saga Medical School, Saga, Japan
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Wassef W. Interventional endoscopy. Curr Opin Gastroenterol 2002; 18:669-77. [PMID: 17033346 DOI: 10.1097/00001574-200211000-00006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Technologic milestones have been achieved in the field of interventional endoscopy. These have resulted in improved hemostasis, more accurate cancer staging, safer and less invasive methods of removing gastric neoplasms, and endoscopic palliation of malignant gastric outlet obstruction via stenting. However, just as these milestones are achieved, new challenges emerge: (1) How much sedation can one use safely? (2) What is the risk of transmitting infection and how can that be prevented? (3) Can scopes be made smaller and more comfortable? (4) Can optics be improved? (5) Can endoscopic repair of gastric perforations be safely performed? In this section, we review some of these issues. First, we will provide an update on the most recent concepts in the field of light sedation and infection control. Then, a review of the most commonly used interventional endoscopy procedures, including hemostasis, endosonography, endoscopic mucosal resection, stenting, and percutaneous gastrostomy tube placements. Finally, an overview of the ongoing research and development in the field of interventional endoscopy and how it can improve patient comfort, diagnostic accuracy, therapeutic efficacy, and training in the future.
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Affiliation(s)
- Wahid Wassef
- Division of Gastroenterology, University of Massachusetts Medical Center, Worcester, Massachusetts 01655, USA.
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