Gastrointestinal perforations: role of endoscopic closure

Sealing the hole: endoscopic management of acute gastrointestinal perforations

Acute perforations are one of the recognised complications of both diagnostic and therapeutic gastrointestinal (GI) endoscopy. The incidence rate varies according to the type of procedure and the anatomical location within the GI tract. For decades, surgical treatment has been the standard of care, but endoscopic closure has become a more popular approach, due to feasibility and the reduction of the burden of surgery. Various devices are available now such as through-the-scope clips, over-the-scope clips, endoscopic suturing devices, stents, bands and omental patch. All have been tested in studies done on humans or animal models, with a reasonable overall technical and clinical success rate, proving efficiency and feasibility of endoscopic closure. The choice of which device to use depends on the site and the size of the perforation. It also depends on availability of thee device and the endoscopist's experience. A number of factors that could predict success of endoscopic closure or favour surgical treatment have been suggested in different studies. After successful endoscopic closure, patients are usually kept nil by mouth and receive antibiotics for a duration that varied between different studies.

Application of novel endoloops to close the defects resulted from endoscopic full-thickness resection with single-channel gastroscope: a multicenter study

BACKGROUND

The key step of the endoscopic full-thickness resection (EFTR) procedure is the successful closure of any gastric wall defect which ultimately avoids surgical intervention. This report presents a new method of closing large gastric defects left after EFTR, using metallic clips and novel endoloops by means of single-channel endoscope.

METHODS

We retrospectively analyzed 68 patients who were treated for gastric fundus gastrointestinal stromal tumors originating from the muscularis propria layer at four institutes between April 2014 and February 2015 and consequently underwent EFTR. The large gastric post-EFTR defects were completely closed with metallic clips and novel endoloops using single-channel endoscope, and all the patients were discharged with subsequent endoscopic and clinical follow-up. Patient characteristics, tumor size, en bloc resection rate, closure operation time, and postoperative adverse events were evaluated.

RESULTS

EFTR was successfully performed on 68 patients [41 male (60 %), 27 female (40 %); median age 61 years, range 38-73], and the en bloc resection rate was 100 %. Complete closure of all the gastric post-EFTR defects was achieved (success rate 100 %). The mean closure operation time was 13 min (range 9-21 min). The mean maximum size of the lesions was 2.6 cm (range 2.0-3.5 cm). One Mallory-Weiss syndrome and one delayed bleeding were resolved with nonsurgical treatment. The wounds were healed in all cases 1 month after the procedure.

CONCLUSIONS

The use of metallic clips and novel endoloops with single-channel endoscope is a relatively safe, easy, and feasible method for repairing large gastric post-EFTR defects.

Management of polypectomy complications

The 2 most significant complications of colonoscopy with polypectomy are bleeding and perforation. Incidence rates for bleeding (0.1%-0.6%) and perforation (0.7%-0.9%) are generally low. Recognition of pertinent risk factors helps to prevent these complications, which can be grouped into patient-related, polyp-related, and technique/device-related factors. Endoscopists should be equipped to manage bleeding and perforation. Currently available devices and techniques are reviewed to achieve hemostasis and close colon perforations.

Closing perforations and postperforation management in endoscopy: esophagus and stomach

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.

Comparison of endoscopic band ligation and endoclip closure of colonic perforation: technical feasibility and efficacy in an ex vivo pig model

BACKGROUND AND AIM

Recent reports have indicated several instances of successful treatment of bowel perforation by using endoscopic band ligation (EBL) when treatment with endoclipping is unsuccessful, but this salvage method has not been investigated in any prospective model. Herein we aimed to compare the technical feasibility and efficacy of EBL and endoclip use in intraluminal closure of colon perforation, in an ex vivo model.

METHODS

Standardized colonic perforations were created using fresh porcine colon and subsequently closed by full-thickness interrupted sutures, endoclip (QuickClip2(TM)), or EBL. Each closure site was tested with compressed air by using a digital pressure monitor for evaluating leak pressure.

RESULTS

No significant differences were noted between the endoclip and EBL in leak pressures. Mean (± SD) pressures for air leakage from the perforations closed using the different devices were as follows: normal colon samples, 52.0 ± 13.2 mmHg; perforations closed with hand-sewn sutures, 32.3 ± 8.3 mmHg; perforations closed with endoclipping, 53.5 ± 22.7 mmHg; and perforations closed with EBL, 50.4 ± 12.5 mmHg. Time taken for closure by EBL was significantly less than that for closure by endoclipping (3.2 ± 1.7 min vs 6.8 ± 1.3 min, P < 0.01). Further, the number of devices used to achieve complete closure in the EBL group was lower than that with endoclipping (1.6 ± 0.5 vs 3.7 ± 0.8, P < 0.01).

CONCLUSION

Endoluminal closure of a 1.5-cm colon perforation with EBL decreased procedure time and was not inferior in leak pressure compared with endoclipping in this ex vivo porcine model.

Endoscopic closure of acute esophageal perforations

Esophageal leak is a life-threatening problem that can result from spontaneous rupture of the esophagus, cancer, anastomotic dehiscence after surgery, or as a complication of endoscopy. During the last decade, developments in the minimally invasive endoluminal approach to the management of esophageal leaks include utilization of endoscopy not only for diagnosis but also for closure of leaks with clips or sutures, bypass of the leaks with stents, and/or endoluminal drainage of mediastinal infection. The aim of this review is to summarize recent advances and the principles of endoscopic management of acute esophageal perforations.

Endoscopic band ligation: beyond prevention and management of gastroesophageal varices

Endoscopic band ligation (EBL) is the preferred endoscopic technique for the endoscopic treatment of acute esophageal variceal bleeding. EBL has also been used to treat nonvariceal bleeding. Recently, Han et al demonstrated that EBL can be a feasible and safe alternate technique for the management of iatrogenic gastric perforation especially in cases in which closure with endoclips is difficult. EBL is technically simpler to perform than other methods and provides a good view of the lesions under direct pressure and suction from the transparent ligation cap. EBL can be used even if the diameter of the perforation is greater than 10 mm or if there is a severe tangential angle. In this commentary, we discuss the efficacy and safety of EBL for the closure of iatrogenic gastrointestinal perforation. We also discuss the advantages and disadvantages of EBL for the treatment of nonvariceal bleeding.

Omentum patch substitute for facilitating endoscopic repair of GI perforations: an early laparoscopic pilot study with a foam matrix plug (with video)

BACKGROUND

Endoscopic perforations are surgically repaired by using an omentum patch. Omentum substitutes may have broader applications particularly in certain sites (eg, esophagus).

OBJECTIVE

Evaluate a self-expandable foam matrix plug as a synthetic omentum substitute for repairing iatrogenic gastric perforations in a 4-week survival pig model.

DESIGN

Experimental pilot study.

SETTING

Laboratory.

INTERVENTION

A laparoscopic plug repair of a 1-cm, full-thickness, gastric perforation was carried out by using either a polyurethane foam matrix plug (FMP, 8 animals) or an omentum plug (OP, 6 animals, control group).

MAIN OUTCOME MEASUREMENTS

Follow-up endoscopy was carried out at 1 and 4 weeks. At necropsy, the perforation site was evaluated for adhesions and histology by using hematoxylin and eosin analysis. A portion of the implant was sent for bacterial and fungal culture.

RESULTS

All procedures were technically simple and successful. Thirteen animals thrived well for 4 weeks. One animal from the FMP group died 3 days postoperatively from diffuse peritonitis because of a misplaced plug. All remaining FMPs were intact at 4 weeks and colonized with mixed bacteria, except one animal presenting with FMP migration after 1 week. Histologically, the FMP group had more prominent inflammation and suppuration as compared with the OP group, all limited to its adjacent tissue.

LIMITATIONS

Animal study.

CONCLUSION

The FMP offered a technically simple and feasible option for repairing iatrogenic gastric perforations. With effective sealing, the clinical outcome is similar to that of an omentum patch repair. Migration and inadequate sealing is a concern, which can lead to peritonitis and sepsis. Further development is needed to improve FMP performance.