Argon plasma coagulation for successful fragmentation and removal of an over-the-scope clip

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.

Current status in endoscopic management of upper gastrointestinal perforations, leaks and fistulas

Recent advancement in endoscopic closure techniques have revolutionized the treatment of gastrointestinal perforations, leaks and fistulas. Traditionally, these have been managed surgically. The treatment strategy depends on the size and location of the defect, degree of contamination, presence of healthy surrounding tissues, patients' condition and the availability of expertise. One of the basic principles of management includes providing a barricade to the flow of luminal contents across the defect. This can be achieved with a wide range of endoscopic techniques. These include endoclips, stenting, suturing, tissue adhesives and glue, and endoscopic vacuum therapy. Each method has their distinct indications and shortcomings. Often, a combination of these techniques is required. Apart from endoscopic closure, drainage procedures by the interventional radiologist and surgical management also play an important role. In this review article, the outcomes of each of these endoscopic closure techniques in the literature is provided in tables, and practical management algorithms are being proposed.

Endoscopic resection using an over-the-scope clip for duodenal neuroendocrine tumors

Background and study aims  Endoscopic resection of duodenal neuroendocrine tumors (DNETs) remains controversial, and its indications are still unclear. This study aimed to evaluate short-term outcomes of a newly developed endoscopic muscularis resection (EMR) method that utilizes an over-the-scope clip (OTSC), termed EMRO, for treating DNETs. Patients and methods  In total, 13 consecutive patients with 14 small (≤ 10 mm) DNETs who underwent EMRO from September 2017 to March 2020 were retrospectively enrolled. EMRO was performed by a single experienced endoscopist. Patients' characteristics and treatment outcomes were assessed. Results  The En bloc and R0 resection rates were 100 % (14/14) and 92.9 % (13/14), respectively. The median pathological resected specimen size was 10 mm, with a median pathological resected tumor size of 6 mm. During the EMRO procedure, there was no occurrence of misplacement of the OTSC to the target lesion. With respect to the pathological resection depth, nine cases (64.3 %) and five cases (35.7 %) were categorized as deep submucosal resection and muscularis resection, respectively, whereas no case was categorized as full-thickness resection. There were no intraoperative or delayed perforations. However, delayed bleeding occurred in two cases. At a median follow-up of 12 months (range 7-36) after EMRO, there was no incidence of local recurrence. At the first follow-up endoscopy performed at 6 months after EMRO, the OTSC was retained in place in two of 14 DNETs (14.3 %). Conclusions  EMRO can be performed safely, by an experienced endoscopist, for small (≤ 10 mm) DNETs.

Methods for Endoscopic Removal of Over-the-Scope Clip: A Systematic Review

AIMS

The over-the-scope clip (OTSC) has recently emerged as a new endoscopic device for treating gastrointestinal bleeding, perforations, fistulas, and leaks. A modified OTSC device (full-thickness resection device, FTRD) has been widely used for endoscopic full-thickness resection. However, there is less experience regarding the indications and methods for OTSC removal. We aimed to summarize the existing methods and indications for OTSC removal.

METHODS

We searched PubMed, Cochrane Library, and ClinicalTrials.gov to identify relevant publications on OTSC removal. The details of OTSC removal, including the methods, indications, success rates, adverse events, and failure causes, were extracted and summarized. A meta-analysis of pooled success rates was conducted using STATA 15.0.

RESULTS

Eighteen articles were included. The reported methods for OTSC removal included (1) grasping forceps, (2) the Nd : YAG laser, (3) argon plasma coagulation, (4) the remOVE system, (5) endoscopic mucosal resection/endoscopic submucosal dissection, and (6) ice-cold saline solution. Indications for OTSC removal were (1) poor healing, (2) OTSC misplacement, (3) repeat biopsy/therapy or further treatment, (4) adverse events after OTSC implantation, (5) removal after recovery, and (6) patient wishes. The pooled success rate of OTSC removal was 89% in patients treated with the remOVE system. Minor bleeding, superficial thermal damage, and superficial mucosal tears were common adverse events. Mucosal overgrowth was the main cause of OTSC removal failure.

CONCLUSIONS

The remOVE system is the best investigated method, with sufficient efficacy and safety for OTSC removal. This is the first systematic review of OTSC removal and provides significant guidance for clinical practice.

Clinical efficacy of the over-the-scope clip device: A systematic review

BACKGROUND

The over-the-scope clip (OTSC) system has been increasingly utilized as a non-surgical option to endoscopically manage refractory gastrointestinal (GI) hemorrhage, perforations/luminal defects and fistulas. Limited data exist evaluating the efficacy and safety of OTSC.

AIM

To determine the clinical success and adverse event (AE) rates of OTSC across all GI indications.

METHODS

A PubMed search was conducted for eligible articles describing the application of the OTSC system for any indication in the GI tract. Any article or case series reporting data for less than 5 total patients was excluded. The primary outcome was the rate of clinical success. Secondary outcomes included: Technical success rate, OTSC-related AE rate and requirement for surgical intervention despite-OTSC placement. Pooled rates (per-indication and overall) were calculated as the number of patients with the event of interest divided by the total number of patients.

RESULTS

A total of 85 articles met our inclusion criteria (n = 3025 patients). OTSC was successfully deployed in 94.4% of patients (n = 2856/3025). The overall rate of clinical success (all indications) was 78.4% (n = 2371/3025). Per-indication clinical success rates were as follows: (1) 86.0% (1120/1303) for GI hemorrhage; (2) 85.3% (399/468) for perforation; (3) 55.8% (347/622) for fistulae; (4) 72.6% (284/391) for anastomotic leaks; (5) 92.8% (205/221) for defect closure following endoscopic resection (e.g., following endoscopic mucosal resection or endoscopic submucosal dissection); and (6) 80.0% (16/20) for stent fixation. AE's related to the deployment of OTSC were only reported in 64 of 85 studies (n = 1942 patients), with an overall AE rate of 2.1% (n = 40/1942). Salvage surgical intervention was required in 4.7% of patients (n = 143/3025).

CONCLUSION

This systematic review demonstrates that the OTSC system is a safe and effective endoscopic therapy to manage GI hemorrhage, perforations, anastomotic leaks, defects created by endoscopic resections and for stent fixation. Clinical success in fistula management appears limited. Further studies, including randomized controlled trials comparing OTSC with conventional and/or surgical therapies, are needed to determine which indication(s) are the most effective for its use.

Long-term assessment of over-the-scope clip (OTSC) behavior after gastric application

Background: The aim of this study was to assess the long-term behavior of the over-the-scope clip (OTSC) after gastric application.Material and methods: A database of all patients who had OTSC placement with regular follow-up at a tertiary hospital between November 2013 and September 2016 was retrospectively analyzed. The incidence, time, and related adverse events of clip attachment and detachment were recorded. The relationship between the position of the clip and detachment was assessed by Fisher's exact test.Results: Seventy-two patients who had gastric OTSC placement due to iatrogenic perforations by endoscopic interventions were included in the study. The overall incidence of clip detachment was 27.8% (20/72). Fisher's exact test confirmed a significant association between clip detachment rate and clip position (p = .005): cardia 50% (3/6); gastric fundus 13.2% (5/38); gastric body 75% (9/16); and gastric antrum 25% (3/12). Except for one patient (5%; 1/20) who experienced minor gastric hemorrhage, there were no complications related to spontaneous clip detachment. There was no delayed bleeding, perforation, or obstruction due to clips staying in place in the long-term.Conclusions: Long-term gastric clip attachment appears to be safe even if spontaneous detachment occurs.

Optimized Training in the Use of Endoscopic Closure Devices

Successful closure of gastrointestinal defects is one of the most important goals for therapeutic endoscopy. Historically, surgical repair was the mainstay of treatment for any gastrointestinal defect; however, surgery is associated with high morbidity and mortality. Endoscopic management of gastrointestinal defects has developed rapidly in recent years and has become more effective, reducing the morbidity and mortality rates, and avoiding surgical interventions. Appropriate use of endoscopic techniques requires extensive knowledge of the devices and their advantages and limitations during practical applications.

Efficacy of Utilizing Argon Plasma Coagulation for Weight Regain in Roux-en-Y Gastric Bypass Patients: a Multi-center Study

BACKGROUND

Endoscopic approaches exist for targeting weight regain after Roux-en-Y gastric bypass (RYGB), including endoscopic suturing, clipping, and sclerotherapy. Argon plasma coagulation (APC) is a noncontact electrocoagulation method, and when used in RYGB patients, it has shown reduction in the diameter of the gastrojejunal anastomosis.

OBJECTIVES

To study the effectiveness of APC for weight regain in terms of weight loss for RYGB patients, from eight bariatric centers.

METHODS

A retrospective chart review was performed for 558 patients at eight bariatric centers in the USA (1) and Brazil (7) who underwent APC procedure between 31st July 2009 and 29th March 2017. APC was performed on patients who regained weight after RYGB procedure.

RESULTS

Upon exploratory analysis of the individual BMI data, the mean BMI decreased slightly during the first 24 months and increased slightly afterwards following the APC intervention. The mean weight was 94.5 ± 18.6 kg and the mean BMI was 34.0 kg/m² at APC. Where data were available, the mean of lowest weight was 67.0 ± 23.0 kg and the mean of lowest BMI was 24.1 kg/m² following gastric bypass. The mean weight loss was 6.5, 7.7, and 8.3 kg at 6, 12, and 24 months, respectively, and the changes in weight over time was statistically significant (p < 0.0001). Multi-level for change model showed the low body mass index (BMI) group (BMI < 30 kg/m²) to have greater TWL than the high BMI (BMI ≥ 30 kg/m²) group at 6, 12, and 24 months. In the low BMI group, the mean TWL was 4.7, 6.1, 6.9, and 2.4%, at 6, 12, and 24 months, respectively. In the high BMI group, the mean TWL was 7.5, 10.4, 13.4, and 3.7%, at 6, 12, 24, and 36 months, respectively. Of the 333 patients in four centers who provided complication information, complications after APC included stenosis (n = 9), GJ ulcer (n = 3), vomiting (n = 3), GJ leakage (n = 2), and melena (n = 1).

CONCLUSION

APC can be useful in reducing the regained weight after RYGB, and patients showed 6-10% total weight loss at 12 months. Randomized trials would be needed to validate the findings.

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.

Endoscopic Closure of Gastrointestinal Fistulae and Leaks

The development of new endoscopic techniques, such as gastrointestinal (GI) stenting, full-thickness suturing, clip application, and use of tissue adhesives, has had a significant impact on management of GI fistulae. These techniques have shown promising results, but further study is needed to optimize the efficacy of long-term closure. The advancement of endoscopic techniques, including the use of the lumen apposing metal stent (LAMS), has allowed for the deliberate creation of fistula tracts to apply endoscopic therapy that previously could not be achieved. This article examines the rapidly evolving area of endoscopic fistula closure and its relationship to LAMS.