Successful closing of duodenal ulcer after endoscopic submucosal dissection with over‐the‐scope clip to prevent delayed perforation

Closure of post‐endoscopic submucosal dissection (ESD) duodenal artificial ulcer is not common in the clinical setting. We consider that post‐ESD ulcer closure by an over‐the‐scope‐clip (OTSC) method is one of the most effective ways to prevent delayed perforation. We report here two cases of mucosal duodenal cancer in a 65‐year‐old woman and in a 78‐year‐old man. Pathological examinations of the resected specimens revealed well‐differentiated adenocarcinomas. In these two clinical cases, we successfully carried out complete closures of post‐ESD duodenal ulcer using OTSC without any complications.     

Over‐the‐scope clip for acute esophageal variceal bleeding

Over‐the‐scope clip (OTSC) has been reported to control non‐variceal bleeding; however, the use of this device for acute variceal hemorrhage (AVH) is very limited. We report our experience regarding the use of OTSC in patients with AVH in terms of technical success and safety. A retrospective clinical experience case series study was conducted from October 2017 to June 2019 at two tertiary care centers. Adult patients with AVH as a result of small varices managed with OTSC after endoscopic band ligation (EBL) failure were enrolled. Standard gastroscope and OTSC ‘type a’ with a cap of 11 mm in diameter were used in all procedures. Total of five patients with chronic liver disease (Child‐Pugh score ≤8) and portal hypertension (hepatic venous pressure gradient, mean 14.4 ± 1.3 mmHg) were included. Four of them presented collapse of the bleeding varix, and one had wall disruption associated with fibrosis secondary to prior banding. We were able to stop AVH in all patients without clip‐related adverse events during a 30‐day follow‐up period. Two patients developed solid food dysphagia after 3 months of clip deployment that resolved after removal using a bipolar cutting device. Twin grasper or anchor were not used to aid or facilitate the approximation of opposite edges in any patient. No additional local therapies or new endoscopic session for variceal eradication were required. This case series shows preliminary success controlling AVH with OTSC after EBL failure in patients with small varices. Esophageal dysphagia may appear as a complication during follow up but it can be resolved by clip removal.     

Endoscopic fibrin sealant closure of duodenal perforation after endoscopic retrograde cholangiopancreatography

Traditionally, perivaterian duodenal perforation can be managed conservatively or surgically. If a large volume of leakage results in fluid collection in the retroperitoneum, surgery may be necessary. Our case met the surgical indication for perivaterian duodenal perforation after endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and endoscopic papillary balloon dilatation. The patient developed a retroperitoneal abscess after the procedures, and a perivaterian perforation was suggested on computed tomography (CT). CT-guided abscess drainage was performed immediately. We unsuccessfully attempted to close the perforation with hemoclips initially. Subsequently, we used fibrin sealant (Tisseel) injection to occlude the perforation. Fibrin sealant injections have been previously used during endoscopy for wound closure and fistula repair. Based on our report, fibrin sealant injection can be considered as an alternative method for the treatment of ERCP-related type II perforations.     

Endoscopic clip placement for the prevention of perforation after colonic endoscopic mucosal resection

Endoscopically placed clips have gained a prominent role in the management of bleeding or perforation during endoscopic mucosal resection of large colonic polyps. Clips may be used to treat intraprocedural complications, but may also be placed prophylactically when patients are at an increased risk for post-procedural bleeding or delayed perforation. Polyp size, location, resection technique, and appearance of the resection defect can all influence the decision on whether to place prophylactic clips. Not all post-polypectomy defects require clip placement. The downsides of clip placement include increased cost and the possibility of “clip artifact” mimicking residual polyp on surveillance examinations. When clipping, attention to proper technique can ensure secure closure of the defect and efficient placement of additional clips. Over-the-scope clips and endoscopic suturing are other strategies which can be used for treatment of bleeding or perforation, though each requires attachment to the scope and training for use.     

Over‐the‐scope clip system: A review of 1517 cases over 9 years

Rescue therapy for gastrointestinal (GI) refractory bleeding, perforation, and fistula has traditionally required surgical interventions owing to the limited performance of conventional endoscopic instruments and techniques. An innovative clipping system, the over‐the‐scope clip (OTSC), may play an important role in rescue therapy. This innovative device is proposed as the final option in endoscopic treatment. The device presents several advantages including having a powerful sewing force for closure of GI defects using a simple mechanism and also having an innovative feature, whereby a large defect and fistula can be sealed using accessory forceps. Consequently, it is able to provide outstanding clinical effects for rescue therapy. This review clarifies the current status and limitations of OTSC according to different indications of GI refractory disease, including refractory bleeding, perforation, fistula, and anastomotic dehiscence. An extensive literature search identified studies reported 10 or more cases in which the OTSC system was applied. A total of 1517 cases described in 30 articles between 2010 and 2018 were retrieved. The clinical success rates and complications were calculated overall and for each indication. The average clinical success rate was 78% (n = 1517) overall, 85% for bleeding (n = 559), 85% (n = 351) for perforation, 52% (n = 388) for fistula, 66% (n = 97) for anastomotic dehiscence, and 95% (n = 122) for other conditions, respectively. The overall and severe OTSC‐associated complications were 1.7% (n = 23) and 0.59% (n = 9), respectively. This review concludes that the OTSC system may serve as a safe and productive device for GI refractory diseases, albeit with limited success for fistula.     

Endoscopic drainage for duodenal hematoma following endoscopic retrograde cholangiopancreatography: A case report

Intramural duodenal hematoma (IDH) is a rare complication following endoscopic retrograde cholangiopancreatography (ERCP). Blunt damage caused by the endoscope or an accessory has been suggested as the main reason for IDH. Surgical treatment of isolated duodenal hematoma after blunt trauma is traditionally reserved for rare cases of perforation or persistent symptoms despite conservative management. Typical clinical symptoms of IDH include abdominal pain and vomiting. Diagnosis of IDH can be confirmed by imaging techniques, such as magnetic resonance imaging or computed tomography and upper gastrointestinal endoscopy. Duodenal hematoma is mainly treated by drainage, which includes open surgery drainage and percutaneous transhepatic cholangial drainage, both causing great trauma. Here we present a case of massive IDH following ERCP, which was successfully managed by minimally invasive management: intranasal hematoma aspiration combined with needle knife opening under a duodenoscope.