Surgical Endoscopic Vacuum Therapy for Defects of the Upper Gastrointestinal Tract

Introduction

Intraluminal therapy used in the gastrointestinal (GI) tract was first shown for anastomotic leaks after rectal resection. Since a few years vacuum sponge therapy is increasingly being recognized as a new promising method for repairing upper GI defects of different etiology. The principles of vacuum-assisted closure (VAC) therapy remain the same no matter of localization: Continuous or intermittent suction and drainage decrease bacterial contamination, secretion, and local edema. At the same time, perfusion and granulation is promoted. However, data for endoscopic vacuum therapy (EVT) of the upper intestinal tract are still scarce and consist of only a few case reports and small series with low number of patients.

Objectives

Here, we present a single center experience of EVT for substantial wall defects in the upper GI tract.

Methods

Retrospective single-center analysis of EVT for various defects of the upper GI tract over a time period of 4 years (2011–2015) with a mean follow-up of 17 (2–45) months was used. If necessary, initial endoscopic sponge placement was performed in combination with open surgical revision.

Results

In total, 126 polyurethane sponges were placed in upper gastrointestinal defects of 21 patients with a median age of 72 years (range, 49–80). Most frequent indication for EVT was anastomotic leakage after esophageal or gastric resection (n?=?11) and iatrogenic esophageal perforation (n?=?8). The median number of sponge insertions was five (range, 1–14) with a mean changing interval of 3 days (range, 2–4). Median time of therapy was 15 days (range, 3–46). EVT in combination with surgery took place in nine of 21 patients (43 %). A successful vacuum therapy for upper intestinal defects with local control of the septic focus was achieved in 19 of 21 patients (90.5 %).

Conclusion

EVT is a promising approach for postoperative, iatrogenic, or spontaneous lesions of the upper GI tract. In this series, EVT was combined with operative revision in a relevant proportion of patients.

     

Endoscopic vacuum therapy of anastomotic leakage and iatrogenic perforation in the esophagus

Background

The management of anastomotic leakage and iatrogenic esophageal perforation has shifted over recent decades from aggressive surgery to conservative and, recently, endoscopic therapy alternatives. The authors present their results for endoscopic vacuum therapy used to treat both entities.

Methods

In the authors’ institution, 17 cases of anastomotic leakage and 7 cases of iatrogenic perforation due to interventional endoscopy or rigid panendoscopy with either intraluminal or intracavitary endoscopic vacuum therapy were treated.

Results

In 23 of 24 cases, the endoscopic treatment was successful. The median duration of therapy was 11 days (range, 4–46 days). All 7 cases of iatrogenic perforation and 16 of 17 anastomotic leakage cases were cured after a median therapy duration of 5 and 12 days, respectively.

Conclusions

Endoscopic vacuum therapy is applicable for a wide range of esophageal defects. In the authors’ experience, it has seemed to be the best choice for iatrogenic perforations and has been a potent supplement in the management of anastomotic leakages.     

Endoscopic Vacuum Therapy in Colorectal Surgery

Introduction

Endoscopic vacuum therapy (EVT) has been established in Germany for the treatment of anastomotic leakage after rectal resection. Continuous or intermittent suction and drainage decrease bacterial contamination, secretion, and local edema promoting perfusion and granulation at the same time. However, data for use and long-term results of EVT in colorectal surgery are still scarce and are often limited by short-term follow-up.

Objectives

Here, we aimed at analyzing the treatment spectrum and long-term outcome of EVT for defects of the lower gastrointestinal tract.

Methods

This is a retrospective single-center analysis of EVT for defects of the lower gastrointestinal tract of different etiology in 41 patients over a time period of 8 years (2007–2015) with a mean follow-up of 36 (2–89) months.

Results

In total, 426 polyurethane sponges were placed in lower GI defects of 41 patients (31 male, 10 female) with a median age of 70 years (range, 29–91). Most frequent indications for EVT were anastomotic leakage after rectal resection (n?=?20), Hartmann’s stump insufficiency (n?=?12), and rectal perforation (n?=?3). The median number of sponge insertions was six (range, 1–37) with a mean changing interval of 3 days (range, 1–5). Median time of therapy was 20 days. A successful vacuum therapy with local control of the septic focus was achieved in 18 of 20 patients (90 %) with anastomotic leakage after rectal resection and in nine of 12 patients with a Hartmann’s stump insufficiency. In 15 of 19 (79 %) patients with a diverting stoma, take-down after successful treatment was possible. Median time to closure was 244 days (range, 152–488 days).

Conclusion

To our knowledge, this retrospective observation of EVT application for rectal lesions represents the largest patient series in literature. EVT has earned its indication in complication management after colorectal surgery and can achieve a successful control of a local septic focus in the majority of patients.

     

Endoskopische Vakuumtherapie bei Ösophagusläsionen

Background

Endoscopic management of leakages and perforations of the upper gastrointestinal tract is gaining in importance as it can significantly reduce the morbidity and mortality of surgical interventions.

Objective

A summary of the current literature with the focus on success rates for endoscopic vacuum therapy (EVT) in the upper gastrointestinal tract is presented. Technical aspects are demonstrated and the role of EVT as a new therapeutic option for esophageal defects of different etiologies is discussed.

Material and methods

After endoscopic assessment of the geometry of the leakage defect a polyurethane foam sponge is cut into the corresponding shape, connected to a nasal gastric tube and endoscopically placed into the defect. Continuous negative pressure of 100–125 mmHg generated by a vacuum pump is applied via the drainage tube resulting in effective drainage of the cavity and the induction of wound healing by formation of granulation tissue. The foam sponge is replaced in the same way every 3–5 days. Technical aspects are demonstrated and the background literature is discussed.

Results

The first series of cases demonstrate excellent healing rates with a very low procedure-related morbidity.

Conclusion

It appears likely that this technique will become the new therapeutic standard for leakages in the upper gastrointestinal tract.

     

Surgical Management of Iatrogenic Perforation of the Gastrointestinal Tract: 15 Years of Experience in a Single Center

Background

Gastrointestinal (GI) tract perforation during endoscopy is a rare but severe complication. The aim of this study was to determine predictors of morbidity and mortality after iatrogenic endoscopic perforation.

Materials and methods

All cases with iatrogenic endoscopic perforation receiving surgery at a tertiary referral center in a 15-year period (2000–2015) were retrospectively analyzed. Demographics, type of endoscopy, site of perforation, operative procedure, morbidity and mortality were analyzed. Multiple logistic regression was used to identify parameters predicting survival.

Results

A total of 106.492 endoscopies were performed, and 82 (0.08%) patients were diagnosed with GI perforation. Most perforations (63.4%) occurred in the lower GI tract, compared to 36.6% in the upper GI tract. In 21 cases (25%), perforation was noticed during endoscopy, whereas 61 perforations (75%) were diagnosed during the further clinical course. Operative care was applied within 24 h in 61%. Surgery of perforations was almost completely performed maintaining the intestinal continuity (68%), whereas diversion was performed in 32%. Mortality was associated with age above 70 (OR 4.89, p = 0.027), ASA class > 3 (OR 4.08, p = 0.018), delayed surgery later than 24 h after perforation (OR 5.9, p = 0.015), peritonitis/mediastinitis intraoperatively (OR 4.68, p = 0.031) and severe postoperative complications with a Clavien–Dindo grade ≥III (OR 5.12, p = 0.023).

Conclusion

The prevalence of iatrogenic endoscopic perforation is low, although it is associated with a serious impact on morbidity and mortality. Delayed management worsens prognosis. To achieve successful management of endoscopic perforations, early diagnosis is essential in cases of deviation from the normal post-interventional course, especially in elderly.

     

Endoscopic Closure of Postoperative Gastrointestinal Leakages and Fistulas with the Over-the-Scope Clip (OTSC)

Background

In contrast to conventional Through-the-Scope Clips, the novel Over-the-Scope Clip (OTSC®) allows endoscopic full thickness closure of gastrointestinal leakages. The purpose of this study was to evaluate the efficacy and safety of the OTSC for the management of postoperative gastrointestinal leakages and fistulas.

Methods

We retrospectively reviewed a series of 14 consecutive patients with postoperative gastrointestinal leakages and fistulas who were treated by OTSC application.

Results

Nine OTSCs were used for upper GI tract leakages; five were used for colorectal leakages. Seventy-nine percent (11/14) of leakages were chronic (treated by OTSC later than postoperative day 14). In nine patients, other therapies preceded OTSC application. Median follow-up time was 5.5 months (range, 0.25–17). Primary technical success was achieved in all (14/14) patients. No adverse events related to the use of the OTSC device were noted. Three early recurrences were observed (two colonic fistulas, one esophageal anastomotic leakage), leading to a long-term success rate of 79 % (11/14). Leakage closure finally was achieved in these three patients by surgery or endoscopic vacuum therapy.

Conclusions

The OTSC system is an effective and safe method for the management of postoperative leakages and fistulas of the gastrointestinal tract. Its exact place in treatment algorithms of postoperative leakages will have to be determined.     

Neue Strategien und Materialien bei der endoskopischen Vakuumtherapie im unteren Gastrointestinaltrakt

Background

Endoscopic vacuum therapy is a widespread method in the postoperative treatment of lower and upper gastrointestinal (GI) tract leakage.

Objective

There is an absence of further technical development of the standardized material from 2007 for the lower GI tract.

Material and methods

New strategies and new materials for endoscopic vacuum therapy are presented.

Results

Alternative strategies in sponge placement, use of open-pore film drainage, use of a multiple sponge system, rinsing catheter, electronic pumps etc. enable the successful treatment of very complex pelvic defects.

Conclusion

The wide variability of pelvic defects often necessitates a change in therapeutic strategies during the course of treatment for an optimized outcome.

     

Endoscopic endoluminal vacuum therapy is superior to other regimens in managing anastomotic leakage after esophagectomy: a comparative retrospective study

Background

Anastomotic leakage after esophagectomy is a life-threatening complication. No comparative outcome analyses for the different treatment regimens are yet available.

Methods

In a single-center study, data from all esophagectomy patients from January 1995 to January 2012, including tumor characteristics, surgical procedure, postoperative anastomotic leakage, leakage therapy regimens, APACHE II scores, and mortality, were collected, and predictors of patient survival after anastomotic leakage were analyzed.

Results

Among 366 resected patients, 62 patients (16 %) developed an anastomotic leak, 16 (26 %) of whom died. Therapy regimens included surgical revision (n = 18), endoscopic endoluminal vacuum therapy (n = 17), endoscopic stent application (n = 12), and conservative management (n = 15). APACHE II score at the initiation of treatment for leakage was the strongest predictor of in-hospital mortality (p < 0.0017). Conservatively managed patients showed mild systemic illness (mean APACHE II score 5) and no mortality. In systemically ill patients matched for APACHE II scores (mean, 14.4), endoscopic endoluminal vacuum therapy patients had lower mortality (12 %) compared to surgically treated (50 %, p = 0.01) cases and patients managed by stent placement (83 %, p = 00014, log rank test). No other clinical or laboratory parameters significantly influenced patient survival.

Conclusions

Endoscopic endoluminal vacuum therapy was the best treatment of anastomotic leakage in systemically ill patients after esophagectomy in this retrospective analysis. It should therefore be considered an important instrument in the management of this disorder.     

The Over-The-Scope-Clip (OTSC) System is Effective in the Treatment of Chronic Esophagojejunal Anastomotic Leakage

Introduction

Management of postoperative esophagojejunal anastomotic leakage after total gastrectomy represents a very challenging event. Surgical repair is difficult, and conservative treatment can predispose to more severe complications. Endoclips and self-expanding stents are useful endoscopic therapeutic options but present some drawbacks. The Over-The-Scope-Clip (OTSC) system has been shown to be appropriate to close acute small gastrointestinal perforations, but its use in the treatment of chronic leakage remains controversial.

Case Series

The present series reports three consecutive chronic esophagojejunal anastomotic leaks successfully treated with OTSC. In all cases, clip application was simple, safe and effective, without early and late complications.

Discussion

The OTSC system may represent a new therapeutic option in the management of postoperative esophagojejunal anastomotic leakage.     

Endoscopic and Pathologic Findings Associated with Clinical Outcomes of Melanoma in the Upper Gastrointestinal Tract

Background

Melanoma that involves the upper gastrointestinal (GI) tract is rare and studies relating to endoscopic and pathologic findings with clinical outcomes are lacking. We reviewed the gross and microscopic patterns of the upper GI tract in primary and metastatic melanoma, and examined their association with clinical outcomes.

Methods

Twenty-nine cases of primary esophageal (n = 19) and metastatic gastric and/or duodenal melanoma (n = 10) that were detected during upper GI endoscopy between 1995 and 2011 were retrospectively analyzed.

Results

Three types of gross patterns were recognized—nodular pattern in 7 cases, mass-forming pattern in 18 cases, and flat pigmented pattern in 4 cases. In primary esophageal melanoma, 13 patients (68.4 %) underwent surgery and 9 received palliative therapy. Of all cases, 22 patients (75.9 %) died of disease progression; the median overall survival period was 12 months (interquartile range [IQR] 4.5–24.5 months), and from recognition of upper GI tract melanoma the median overall survival period was 9 months (IQR 3.5–17.0 months). In primary esophageal cases, skin melanoma stage better discriminated the patients with good prognosis than the esophageal cancer stage. The flat pigmented gross pattern proved to be a good prognostic factor in primary and metastatic GI tract melanomas (p = 0.016 and p = 0.046, respectively).

Conclusions

Melanoma of the GI tract is a highly aggressive disease with a poor prognosis, both in primary and metastatic cases. However, in primary esophageal melanoma, careful inspection of the mucosa during endoscopic examination followed by surgical resection may result in extended survival.     

Performance of the OTSC System in the endoscopic closure of iatrogenic gastrointestinal perforations: a systematic review

Background

Reliable closure is a prerequisite for conventional and innovative endoscopic procedures, such as NOTES. The purpose of this study is the systematic evaluation of the procedural and clinical success rates in closure of iatrogenic gastrointestinal perforations and acute anastomotic leaks by means of the over-the-scope-clip system (OTSC^®).

Design

PubMed and other sources were searched systematically for clinical and preclinical research on the evaluation of the OTSC System for closure of gastrointestinal perforations and leaks. Appraisal of studies for inclusion and data extraction was performed independently by two reviewers using an a priori determined data extraction grid. Major endpoints to be extracted were data on procedural success (successful clip application) and clinical access (durable closure of defect without secondary adjunct therapy).

Results

A total of 17 clinical research articles/abstracts and 22 preclinical research articles/abstracts were identified. The examined clinical studies comprised case series and clinical single-arm studies. The reviewed studies revealed a consistently high mean rate of procedural success of 80–100 % and durable clinical success of 57–100 %. An identified major drawback preventing successful clip application was occurrence of fibrotic or inflamed lesion edges. Usage of the OTSC System was accompanied by neither major clip-related nor application-related complication. In experimental settings, closure of larger perforations and gastric access sites of NOTES or endoscopic full-thickness resection were achieved with high rates of success.

Conclusions

Because randomized, clinical trials are not available in this field of indication, the evaluation is based on small case series. Nevertheless, by pooling all experience gained, we conclude that endoscopic closure of iatrogenic gastrointestinal perforations and acute anastomotic leaks by means of the OTSC System is a safe and effective method.     

Clipping for endoscopic perforations: initial success but late complication requiring surgery

Introduction

This response discusses the article by Kim and colleagues entitled "endoscopic clip closure versus surgery for the treatment of iatrogenic colon perforations developed during diagnostic colonoscopy: a review of 115,285 patients". Iatrogenic colonoscopic perforation, although uncommon, implies serious management problems for endoscopists and surgeons. Nonoperative treatment currently is recommended under certain conditions, and endoscopic clips can primarily close iatrogenic perforations, helping to avoid surgery. Of the 27 colonoscopic perforation cases presented in the article by Kim and colleagues, 16 were managed by endoscopic clipping closure and 11 by primary surgery. Conservative treatment failed for three patients. Only perforation size obtained statistical significance among the nine variables contrasted between the 11 cases with primary surgery and the 13 cases with successful endoscopic clipping. The results for the three patients whose endoscopic closure failed are not reported.

Authors′ opinion

The authors of this letter think it would have been interesting if these three patients had been included in the analysis due to the high importance of discovering factors that can predict failure of endoscopic clipping for perforations.

Conclusions

To call attention to possible late complications requiring surgery even when initial conservative management of endoscopic perforation succeeds, the authors of this letter present a case of a colocutaneous (actually, sigmoid-scrotal) fistula in a patient 2 weeks after an apparently successful closure of colonoscopic perforation with an “over-the-scope” clip.     

The role of clips in preventing migration of fully covered metallic esophageal stents: a pilot comparative study

Background

Migration is the most common complication of the fully covered metallic self-expanding esophageal stent (SEMS). This study aimed to determine the potential preventive effect of proximal fixation on the mucosa by clips for patients treated with fully covered SEMS.

Methods

In this study, 44 patients (25 males, 57%) were treated with fully covered SEMS including 22 patients with esophageal stricture (4 malignant obstructions, 6 anastomotic strictures, and 12 peptic strictures) and 22 patients with fistulas or perforations (10 anastomotic leaks, 4 perforations, and 8 postbariatric surgery fistulas). The Hanarostent (n?=?25), Bonastent (n?=?5), Niti-S (n?=?12), and HV-stent (n?=?2) with diameters of 18 to 22?mm and lengths of 80 to 170?mm were used. Two to four clips (mean, 2.35?±?0.75 clips) were used consecutively in 23 patients to fix the upper flared end of the stent with the esophageal mucosal layer. Stent migration and its consequences were collected in the follow-up assessment with statistical analysis to compare the patients with and without clip placement.

Results

No complication with clip placement was observed, and the retrieval of the stent was not unsettled by the persistence of at least one clip (12 cases). Stent migration was noted in 15 patients (34%) but in only in 3 of the 23 patients with clips (13%). The number of patients treated to prevent one stent migration was 2.23. The predictive positive value of nonmigration after placement of the clip was 87%. In the multivariate analysis, the fixation with clips was the unique independent factor for the prevention of stent migration (odds ratio, 2.3; 95% confidence interval, 0.10?C0.01; p?=?0.03).

Conclusions

Anchoring of the upper flare of the fully covered SEMS with the endoscopic clip is feasible and significantly reduces stent migration.     

Association Between Circular Stapler Diameter and Stricture Rates Following Gastrointestinal Anastomosis: Systematic Review and Meta-analysis

Background

Stricture is a common complication of gastrointestinal (GI) anastomoses, associated with impaired quality of life, risk of malnutrition, and further interventions. This systematic review and meta-analysis aimed to determine the association between circular stapler diameter and anastomotic stricture rates throughout the GI tract.

Methods

A systematic literature search of EMBASE, MEDLINE and Cochrane Library was performed. The primary outcome was the rate of radiologically or endoscopically confirmed anastomotic stricture. Pooled odds ratios (OR) were calculated using random-effects models to determine the effect of circular stapler diameter on stricture rates in different regions of the GI tract.

Results

Twenty-one studies were identified: seven oesophageal, twelve gastric, and three lower GI. Smaller stapler sizes were strongly associated with higher anastomotic stricture rates throughout the GI tract. The oesophageal anastomosis studies showed; 21 versus 25 mm circular stapler: OR 4.39 ([95% CI 2.12, 9.07]; P?<?0.0001); 25 versus 28/29 mm circular stapler: OR 1.71 ([95% CI 1.15, 2.53]; P?<?0.008). Gastric studies showed; 21 versus 25 mm circular stapler: OR 3.12 ([95% CI 2.23, 4.36]; P?<?0.00001); 25 versus 28/29 mm circular stapler: OR 7.67 ([95% CI 1.86, 31.57]; P?<?0.005). Few lower GI studies were identified, though a similar trend was found: 25 versus 28/29 mm circular stapler: pooled OR 2.61 ([95% CI 0.82, 8.29]; P?=?0.100).

Conclusions

The use of larger circular stapler sizes is strongly associated with reduced risk of anastomotic stricture in the upper GI tract, though data from lower GI joins are limited.

     

Endoscopic muscularis dissection for upper gastrointestinal subepithelial tumors originating from the muscularis propria

Background and aims

Based on our experience with endoscopic submucosal dissection (ESD) and new endoscopic techniques for endoscopic closure of iatrogenic upper gastrointestinal (upper-GI) perforations, we developed methods to remove upper-GI subepithelial tumors (SETs) originating from the muscularis propria by endoscopic?muscularis dissection (EMD). The aim of this study is to evaluate the clinical feasibility and safety of EMD.

Methods

31 patients with upper-GI SETs originating from the muscularis propria were treated by EMD. The EMD differed from ESD in (1) precutting the overlying mucosa above the lesion by using snare or longitudinal incision instead of circumferential incision, (2) dissecting the complete tumors away from submucosal and muscularis propria tissue by electrical dissection combined with blunt dissection, and (3) closing the wound with clips. Perforations occurring during dissection were closed by endoscopic methods.

Results

30 of 31 tumors were resected?completely (96.8 %). One esophageal lesion was resected partially because of severe adhesions with surrounding tissue. Mean resected tumor size was 22.1?mm?×?15.5?mm, and mean operation time was 76.8?min (range 15–330?min). Histological diagnosis was gastrointestinal stromal tumor (GIST) in 16 lesions [6 esophageal, 3 cardial, 7 gastric; 6 very low risk and 10 low risk according to the National Institutes of Health (NIH) risk classification] and leiomyoma in 15 lesions (8 esophageal, 4 cardial, 3 gastric). No patient developed delayed hemorrhage. Perforation occurred in four patients (12.9 %), all of which were managed successfully by endoscopic techniques. The mean follow-up time was 17.7?months (range 7–35?months). Follow-up found no tumor recurrence in any patient.

Conclusions

In this early experience, EMD appears to be a feasible and minimally invasive treatment for some patients with upper-GI SETs originating from the muscularis propria. Although there is a higher risk of perforation than with ESD, this will improve with extended practice, and perforations have become manageable endoscopically.     

Management of non-acute gastrointestinal defects using the over-the-scope clips (OTSCs): a retrospective single-institution experience

Introduction

Advanced endoscopic techniques provide novel therapies for complications historically treated with surgical interventions. Over-the-scope clips (OTSCs) have recently been shown to be effective at endoscopic closure of gastrointestinal (GI) defects. We hypothesize that by following classic surgical principles of fistula management, a high rate of long-term success can be achieved with endoscopic closure of non-acute GI tract defects.

Methods

A retrospective review of a single-institution prospectively maintained database (2012–2015) of all patients referred for the management of GI leaks or fistulae who underwent attempted closure with the OTSC system (Ovesco, Germany) was performed. Acute perforations were excluded. The primary endpoint was long-term success defined by the absence of radiographic or clinical evidence of leak or fistula during follow-up. Patients were stratified by success or failure of OTSC closure and compared with Fisher’s exact and Mann–Whitney U tests.

Results

We identified 22 patients with 28 defects (22 fistulae and 6 leaks). Most patients were female (59 %) with a mean age of 54 years (±14), median BMI of 29, and prior bariatric procedure (55 %). Comorbidities included smoking history (68 %) and diabetes (23 %). The majority of defects were solitary (64 %), involved the upper GI tract (82 %), and had been present for >30 days (50 %). Multiple therapeutic interventions were necessary in 46 % of defects. There were no adverse outcomes related to OTSC placement or misfiring. Endoscopic adjuncts were used in 61 % of cases. Overall success rate was 82 % (100 % for leaks and 76 % for fistulae) at a median follow-up of 4.7 months (IQR 2.1–8.4 months). Predictors of success and failure could not be distinguished due to limited sample size.

Conclusions

Over-the-scope clips can be safely and effectively used in patients presenting with GI leaks and fistulae. Further research is required to characterize the determinants of long-term success and risk factors for failure.

     

Peri-Operative Bowel Perforation in Early Stage Colon Cancer is Associated with an Adverse Oncological Outcome

Background

The presence of an inflammatory response resulting from bowel perforation or anastomotic leakage has been suggested to enhance recurrence rates in colorectal cancer patients. Currently, it is unknown if bowel perforation or anastomotic leakage has prognostic significance in early stage colon cancer patients. In this study, the impact of peri-operative bowel perforation including anastomotic leakage on disease-free survival of stage I/II colon cancer patients was investigated.

Methods

Prospective follow up data of 448 patients with stages I/II colon cancer that underwent resection were included. Patients who died within 3?months after initial surgery were excluded.

Results

Median follow up was 56.0?months. Patients with peri-operative bowel perforation (n?=?25) had a higher recurrence rate compared to patients without perforation (n?=?423), 36.0?% vs. 16.1?% (p?=?0.01). Disease-free survival was significantly worse for the perforation group compared to patients without perforation (p?=?0.004). Multivariate analysis including T-stage, histological grade, and adjuvant chemotherapy showed peri-operative bowel perforation to be an independent factor significantly associated with disease recurrence (odds ratio, 2.7; 95?% CI, 1.1?C6.7).

Conclusion

Peri-operative bowel perforation is associated with increased recurrence rates and impaired disease-free survival in early-stage colon cancer patients.     

Endoscopic clip closure versus surgery for the treatment of iatrogenic colon perforations developed during diagnostic colonoscopy: a review of 115,285 patients

Background

Although the incidence of perforation after endoscopic procedures of the colon is low, the rising number of diagnostic colonoscopies could pose relevant health problems. Optimizing treatment may reduce the probability of severe complications. This study aimed to determine perforation frequency and the management of perforations that occurred during diagnostic colonoscopy.

Methods

A retrospective review of patient records was performed for all patients with iatrogenic colonic perforations after sigmoidoscopy/colonoscopy from 2000 to 2011 in three institutions of The Catholic University of Korea. The patients’ demographic data, endoscopic procedure information, perforation location, therapy, and outcomes along with different therapeutic strategies were recorded.

Results

In the 12-year period, a total of 115,285 diagnostic sigmoidoscopic/colonoscopic procedures were performed. A total of 27 perforations occurred. Sixteen patients underwent endoscopic clipping, of which three patients failed and were referred for surgery. Fourteen patients in total underwent surgery for perforation. Endoscopic clip closure was successful in 81 % of the patients. No perforation-related major morbidity or mortality occurred.

Conclusion

Endoscopic repair using clips can be effective for the treatment of colon perforations that occur during diagnostic colonoscopy.     

Over-the-scope clip (OTSC) represents an effective endoscopic treatment for acute GI bleeding after failure of conventional techniques

Background

Through-the-scope clips are commonly used for endoscopic hemostasis of gastrointestinal (GI) bleeding, but their efficacy can be suboptimal in patients with complex bleeding lesions. The over-the-scope clip (OTSC) could overcome the limitations of through-the-scope clips by allowing compression of larger amounts of tissue, allowing a more efficient hemostasis. We analyzed the use of OTSC in a consecutive case series of patients with acute GI bleeding unresponsive to conventional endoscopic treatment modalities.

Methods

In a retrospective analysis of prospectively collected data in tertiary referral centers, patients undergoing emergency endoscopy for severe acute nonvariceal GI bleeding were treated with the OTSC after failure of conventional techniques. All patients underwent repeat endoscopy 2–4 days after the procedure. Data analysis included primary hemostasis, complications, and 1-month follow-up clinical outcome.

Results

During a 10-month period, 30 patients entered the study consecutively. Bleeding lesions unresponsive to conventional endoscopic treatment (saline/adrenaline injection and through-the-scope clipping) were located in the upper and lower GI tract in 23 and 7 cases, respectively. Primary hemostasis was achieved in 29 of 30 cases (97 %). One patient with bleeding from duodenal bulb ulcer required emergent selective radiological embolization. Rebleeding occurred in two patients 12 and 24 h after the procedure; they were successfully treated with conventional saline/adrenaline endoscopic injection.

Conclusions

OTSC is an effective and safe therapeutic option for severe acute GI bleeding when conventional endoscopic treatment modalities fail.     

Risk Factors for Esophagojejunal Anastomotic Leakage After Elective Gastrectomy for Gastric Cancer

Objective

The aim of this study was to investigate the correlation between intraoperative anastomotic troubles and the incidence of esophagojejunal anastomotic leakage (EJAL), and to identify risk factors for EJAL after elective gastrectomy for gastric cancer.

Methods

This study reviewed the medical and surgical records of 327 patients who underwent elective gastrectomy followed by esophagojejunostomy. A multivariate analysis was performed to determine the risk factors for EJAL.

Results

An EJAL occurred in 19 patients (5.8?%). A multivariate analysis demonstrated that hemoglobin A1c ??7.0?% (p?<?0.01), chronic renal failure (p?<?0.01), proximal gastrectomy (p?<?0.05), and anastomotic trouble during construction of the esophagojejunostomy (p?<?0.01) were independent predictors for EJAL. Anastomotic trouble during construction of esophagojejunostomy occurred in 20 patients (6.1?%), and EJAL occurred in 6 of these 20 patients (30?%). Four of ten patients (40?%) in whom an incomplete anastomosis was repaired by suturing during surgery had an EJAL, while none of seven patients who underwent re-anastomosis had this complication.

Conclusions

EJAL is strongly associated with intraoperative technical errors. To reduce this complication, proper anastomotic techniques are required. Re-anastomosis should be performed when an incomplete anastomosis is discovered during surgery.