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

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          Abstract

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

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          A new endoscopic over-the-scope clip system for treatment of lesions and bleeding in the GI tract: first clinical experiences.

          Andreas Kirschniak, Thomas Kratt, Dietmar Stüker … (2007)
          We report on 11 patients with gastric or colonic bleeding or lesions who were treated with a new endoscopic over-the-scope clip (OTSC) system. The aim of this retrospective analysis was the evaluation of the clinical outcome and description of the new endoscopic device. The data of the patients were evaluated retrospectively. The OTSC system is composed of an application cap, which is mounted onto the distal tip of the endoscope and a connected releasing mechanism, installed on the handle of the scope. Two different variants of the clip, consisting of a shape-memory alloy (nitinol) are available: the "traumatic" and the "atraumatic" versions. In contrast to common endoscopic clips, the OTSC is able to compress larger quantities of tissue. We treated 11 patients (range, 51-84 years; 8 men, 3 women) with severe bleeding or deep wall lesions, or perforations of the GI tract. All treatments were primarily successful, hemostasis was achieved, and lesions could be closed. We reexamined the patients after the intervention and did not see any complications that could be ascribed to the clip itself or to the applicator cap. The OTSC system is a new tool for the endoscopic compression of tissue. Indications for its use are difficult nonvaricose bleedings and lesions or perforations of the GI tract.
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            Colonoscopic perforations: a review of 30,366 patients.

            Eline Luning Prak, C. Rosman, W. Barendregt … (2007)
            Although the incidence of perforation after endoscopic procedures of the colon is low, the rising number of procedures could pose relevant health problems. Recognizing risk factors and optimizing treatment may reduce perforation incidence and the probability of (severe) complications. This study aimed to determine perforation frequency and the management of endoscopic colonoscopic perforation. A retrospective review of patient records was performed for all patients with iatrogenic colonic perforations after sigmoido/colonoscopy between 1990 and 2005. The patients' demographic data, endoscopic procedural information, perforation location, therapy, and outcome were recorded. In the 16-year period, 30,366 endoscopic colonic procedures were performed. In total, 35 colonic perforations occured (0.12%). All the patients underwent a laparotomy: for primary repair in 18 cases (56%), for resection with anastomosis in 8 cases (25%), and for resection without anastomosis in 6 cases (19%). In three patients (8.6%), no perforation was found. The postoperative course was uncomplicated in 21 cases (60%) and complicated in 14 cases (40%), including mortality for 3 patients (8.6% resulting from perforations and 0.01% resulting from total endoscopic colon procedures). The relative risk ratio of colonoscopic and sigmoidoscopic procedures for perforations was 4. Therapeutic procedures show a delay in presentation and diagnosis compared with diagnostic procedures. Of the 35 perforations, 26 (74%) occurred in the sigmoid colon. Iatrogenic colonic perforation is a serious but rare complication of colonoscopy. A perforation risk of 0.12% was found. The perforation risk was higher for colonoscopic procedures than for sigmoidoscopic procedures. The sigmoid colon is the area at greatest risk for perforation. Immediate operative management, preferably primary repair and sometimes resection, appears to be a good strategy for most patients.
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              Randomized controlled trial comparing endoscopic clips and over-the-scope clips for closure of natural orifice transluminal endoscopic surgery gastrotomies.

              R Rothstein, M Vassiliou, D von der Weid (2009)
              Secure and reliable endoscopic closure is of paramount importance before clinical introduction of transgastric natural orifice transluminal endoscopic surgery (NOTES). Gastrotomy closure in humans using standard endoclips has been reported. The aim of this study was to assess the safety of standard endoclip closure and to compare it to a new over-the-scope clip (OTSC) specifically designed for gastrotomy closure. Gastric wall puncture and balloon dilation followed by peritoneoscopy was carried out in 20 female swine. After randomization, closure of the gastric incision was performed using a tissue approximation grasper and either endoclips or OTSCs. Mean (+/- SD) time for gastrotomy closure using endoclips was 31.5 +/- 24.2 minutes (range 8 - 88 minutes) compared with 8.5 +/- 9.1 minutes (range 2 - 31 minutes) using OTSC (P = 0.002). No intraoperative complications occurred. Laparoscopic leak tests with insufflation and saline immersion demonstrated three minor leaks and one major leak in the endoclip closures. No leaks were observed in the OTSC group. At necropsy, complete sealing of the gastrotomy sites was found in all OTSC closures. Small, localized perigastric abscesses were observed in two animals in the OTSC group and in three animals in the endoclip group. One animal in the endoclip group was sacrificed prematurely due to signs of sepsis and was found to have gross peritonitis secondary to a leak. At necropsy, evidence of peritonitis was identified in two other animals in the endoclip group. NOTES gastrotomy closure using standard endoclips, even with a tissue approximation grasper, is associated with an increased risk of leakage and intra-abdominal infection compared with OTSC. The significance of perigastric abscesses, which were seen in both groups, warrants further investigation. Georg Thieme Verlag KG Stuttgart New York.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Clin Endosc
                Journal ID (iso-abbrev): Clin Endosc
                Journal ID (publisher-id): CE
                Title: Clinical Endoscopy
                Publisher: The Korean Society of Gastrointestinal Endoscopy
                ISSN (Print): 2234-2400
                ISSN (Electronic): 2234-2443
                Publication date (Print): March 2014
                Publication date (Electronic): 31 March 2014
                Volume: 47
                Issue: 2
                Pages: 178-182
                Affiliations
                Digestive Disease Center, Soonchunhyang University Hospital, Seoul, Korea.
                Author notes
                Correspondence: Joo Young Cho. Digestive Disease Center, Soonchunhyang University Hospital, 59 Daesagwanro, Yongsan-gu, Seoul 140-743, Korea. Tel: +82-2-709-9202, Fax: +82-2-709-9696, cjy6695@ 123456dreamwiz.com
                Article
                DOI: 10.5946/ce.2014.47.2.178
                PMC ID: 3994261
                PubMed ID: 24765601
                SO-VID: eea808f0-7fc9-4e3e-b2ec-0d9a68e98391
                Copyright © Copyright © 2014 Korean Society of Gastrointestinal Endoscopy
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 05 February 2013
                Date revision received : 28 March 2013
                Date accepted : 28 March 2013
                Funding
                Funded by: Soonchunhyang University Research Fund
                Categories
                Subject: Case Report

                ScienceOpen disciplines: Radiology & Imaging
                Keywords: over-the-scope clip,natural orifice endoscopic surgery,fistula,subepithelial tumor,anastomosis
                Data availability:
                ScienceOpen disciplines: Radiology & Imaging
                Keywords: over-the-scope clip, natural orifice endoscopic surgery, fistula, subepithelial tumor, anastomosis

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