Endoscopic clips for closing esophageal perforations: case report and pooled analysis

BACKGROUND: Acute and chronic esophageal perforations have traditionally been treated with surgery or a conservative approach. Recently, endoscopic repair has been reported in some case reports. OBJECTIVE: To describe a case of a chronic esophagoperitoneal fistula successfully closed by endoscopic clips after several failed reoperations and stent placement. To perform a pooled analysis of the reports describing such closures. DESIGN: Case report and pooled analysis. SETTING: Tertiary-care hospitals. PATIENTS: Our patient presented with mature perforation in the distal esophagus caused by laparoscopic band gastroplasty. Patients for pooled analysis identified by a MEDLINE search (1966 to January 2007) performed for all the English language articles that reported esophageal perforation/fistulae and endoscopic clips. INTERVENTIONS: Endoscopic clip application after ablation of epithelialized edges in our patient. Pooled analyses for demographic and perforation variables, along with predictors for closure time after clipping, were performed. MAIN OUTCOME MEASUREMENTS: Closure of esophageal perforations. RESULTS: The fistula in our patient closed in 3 weeks after endoscopic clipping. The literature review identified a total of 11 articles that describe 17 patients (acute 7, intermediate 4, and chronic 6). The most common cause was iatrogenic (65%), and the size of the perforation ranged from 3 to 25 mm. The median healing time after clipping was 18 days (interquartile range 6-26). Both univariable and multivariable analyses identified only the duration of perforation as a significant predictor of closure time, P values .003 and .02, respectively. LIMITATIONS: Small sample size, nonrandomized sample. CONCLUSIONS: Endoclips may be effective for closing both acute and chronic esophageal perforations. The duration of the perforation is a significant factor for predicting closure time.     

Clinical experience of esophageal perforation occurring with endoscopic submucosal dissection

Esophageal perforation occurring during or after endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) is a rare, but serious complication. However, reports of its characteristics, including endoscopic imaging and management, have not been fully detailed. To analyze and report the clinical presentation and management of esophageal perforations occurred during or after EMR/ESD. Four hundred seventy‐two esophageal neoplasms in 368 patients were treated (171 EMR; ESD 306) at Northern Yokohama Hospital from 2003 to 2012. Esophageal perforation occurred in a total of seven (1.9%) patients, all of whom were male and had undergone ESD. The etiology of perforation was: three (42.9%) intraoperative; three (42.9%) balloon dilatation for stricture prevention; one (14.2%) due to food bolus impaction. All cases were managed non‐operatively based on the comprehensive assessment of clinical severity, extent of the injury, and the time interval from perforation to treatment onset. Conservative management included (i) bed rest and continuous monitoring to determine the need for operative intervention; (ii) fasting and intravenous fluid infusion/ tube feeding; and (iii) intravenous antibiotics. All defects closed spontaneously, save one case where closure was achieved by endoscopic clipping. Surgery was not required. Conservative management for esophageal perforation during advanced endoscopic resection is may be possible when there is no delay in diagnosis or treatment. Decision‐making should be governed purely by multidisciplinary discussion.     

Recurrent spontaneous esophageal rupture

Spontaneous rupture of the esophagus is a relatively uncommon event, and recurrent rupture is extremely rare. We present a patient who experienced and survived 2 spontaneous perforations of the esophagus, occurring 6 years apart. A 43-year-old man was admitted to our hospital with upper abdominal pain after vomiting. Esophagoscopy, esophagogram, and computed tomography were suggestive of esophageal rupture. Emergency left thoracolaparotomy revealed a 20-mm perforation of the left lower esophageal wall that had been previously repaired. After the perforation was repaired with a single-layer closure, the mediastinum and pleural cavity were drained. The patient recovered well and was discharged from the hospital on postoperative day 29. To the best of our knowledge, only 7 previous cases of recurrent spontaneous esophageal perforation have been reported in the literature.     

Spontaneous esophageal rupture responding to simple suture closure, drainage, and percutaneous endoscopic gastrostomy (PEG): case report

Spontaneous esophageal rupture is a rare disease, and the diagnosis and treatment have not been fully established. Herein we present a 55-year-old man with spontaneous esophageal rupture who was successfully treated using simple suture closure, drainage, and intraoperative percutaneous endoscopic gastrostomy. He was brought to the emergency room after vomiting gastric contents and blood and then experiencing chest pain. On admission, vital signs were normal. Emergency endoscopy was performed for hemostasis, and spontaneous esophageal rupture was diagnosed. As chest computed tomography suggested intrathoracic perforation, surgery was performed about 8 h after onset. Surgery confirmed spontaneous esophageal rupture localized in the mediastinum. Simple suture closure, drainage, and intraoperative endoscopic gastrostomy were performed. On postoperative day (POD) 1, the patient was weaned off artificial ventilation, and enteral feeding through PEG was initiated. Oral intake was restarted on POD 10. The patient was discharged on POD 16.     

经内镜钛夹封闭治疗胃、十二指肠急性穿孔

目的 探讨经内镜钛夹封闭对胃、十二指肠急性穿孔治疗的价值。方法 对22例消化性溃疡导致或内镜诊治时出现的胃、十二指肠急性穿孔患者进行内镜下钛夹封闭治疗。结果 内镜下钛夹封闭成功19例(86．4％)，其中一次封闭成功14例(73．7％)，24h后内镜复查补充封闭5例(26．3％)。封闭失败转外科手术治疗3例。内镜下钛夹封闭效果与胃、十二指肠穿孔部位、原因及大小有关。结论 内镜下钛夹封闭是治疗消化性溃疡导致或内镜诊治出现的胃、十二指肠急性穿孔的有效方法。     

Esophageal perforation: the importance of early diagnosis and primary repair

Esophageal perforation is associated with high morbidity and mortality rates, particularly if not diagnosed and treated promptly. Despite the many advances in thoracic surgery, the management of patients with esophageal perforation remains controversial. We performed a retrospective clinical review of 36 patients, 15 women (41.7%) and 21 men (58.3%), treated at our hospital for esophageal perforation between 1989 and 2002. The mean age was 54.3 years (range 7-76 years). Iatrogenic causes were found in 63.9% of perforations, foreign body perforation in 16.7%, traumatic perforation in 13.9% and spontaneous rupture in 5.5%. Perforation occurred in the cervical esophagus in 12 cases, thoracic esophagus in 13 and abdominal esophagus in 11. Pain was the most common presenting symptom, occurring in 24 patients (66.7%). Dyspnea was noted in 14 patients (38.9%), fever in 12 (33.3%) and subcutaneous emphysema in 25 (69.4%). Management of esophageal perforation included primary closure in 19 (52.8%), resection in seven (19.4%) and non-surgical therapy in 10 (27.8%). The 30-day mortality was found to be 13.9%, and mean hospital stay was 24.4 days. In the surgically treated group the mortality rate was three of 26 patients (11.5%), and two of 10 patients (20%) in the conservatively managed group. Survival was significantly influenced by a delay of more than 24 h in the initiation of treatment. Primary closure within 24 h resulted in the most favorable outcome. Esophageal perforation is a life threatening condition, and any delay in diagnosis and therapy remains a major contributor to the attendant mortality.     

Management of adverse events related to endoscopic resection of upper gastrointestinal neoplasms: Review of the literature and recommendations from experts

Prevention therapy is recommended for lesions >1/2 of the esophageal circumference. Locoregional steroid injection is recommended for lesions >1/2–3/4 of the esophageal circumference and oral steroids are recommended for lesions >1/2 of the subtotal circumference. For lesions of the entire circumference, oral steroid combined with injection steroid is considered. Endoscopic balloon dilatation (EBD) is the first choice of treatment for stricture after esophageal endoscopic submucosal dissection (ESD). Radical incision and cutting or self‐expandable metallic stent can be considered for refractory stricture after EBD. In case of intraoperative perforation during esophageal ESD, endoscopic clip closure should be initially attempted. Surgery is considered for treatment of delayed perforation. Current standard practice for prevention of delayed bleeding after gastric ESD includes prophylactic coagulation of vessels on post‐ESD ulcers and giving proton pump inhibitors. Chronic kidney disease stage 4 or 5, multiple antithrombotic drug use, anticoagulant use, and heparin bridging therapy are high‐risk factors for delayed bleeding after gastric ESD. Intraoperative perforation during gastric ESD is initially managed by endoscopic clip closure. If endoscopic clip closure is difficult, other methods such as over‐the‐scope clip (OTSC), polyglycolic acid (PGA) sheet shielding etc. are attempted. Delayed perforation usually requires surgical intervention, but endoscopic closure by OTSC or PGA sheet may be considered. Resection of three‐quarters of the circumference is a risk factor for stenosis after gastric ESD. Giving prophylactic local steroid injection and/or oral steroid is reported, but effectiveness has not been fully verified as has been done for esophageal stricture. The main management method for gastric stenosis is EBD but it may cause perforation.     

SUCCESSFUL ENDOSCOPIC CLOSURES OF COLONIC PERFORATIONS REQUIRING ABDOMINAL DECOMPRESSION AFTER ENDOSCOPIC MUCOSAL RESECTION AND ENDOSCOPIC SUBMUCOSAL DISSECTION FOR EARLY COLON CANCER

Endoscopic submucosal dissection (ESD) for colorectal cancer is not widely accepted because of its technical difficulty and the risk of perforation. In addition, the risk of peritonitis cannot be completely eliminated even if a perforation is closed successfully. Reported here are two cases of early colon cancer in which the patients sustained iatrogenic perforations of the ascending colon during conventional endoscopic mucosal resection and of the sigmoid colon during ESD, respectively, requiring abdominal decompression with an 18 G Medicut needle. Both of these perforations were successfully treated by endoscopic clipping. In conclusion, conservative medical management may be possible in patients who have undergone successful closure of colonic perforations using endoscopic clipping. In order to perform immediate endoscopic closure, abdominal decompression has been useful to decrease patient discomfort and colonic lumen collapse. Now, CO₂ insufflation is being used effectively for the prevention of pneumoperitoneum.     

Successful outcomes of a novel endoscopic treatment for GI tumors: endoscopic submucosal dissection with a mixture of high-molecular-weight hyaluronic acid, glycerin, and sugar

BACKGROUND: Endoscopic submucosal dissection (ESD) has recently been developed for endoscopic treatment of GI tumors, which enables us to resect even large tumors en bloc. However, a considerable frequency of perforation has become another problem. The best way to prevent perforation is to create a sufficient submucosal fluid cushion (SFC). The aim of this study is to find out the feasibility of ESD by using a mixture of 1900 KDa hyaluronic acid (Suvenyl) and a 10% glycerin plus 5% fructose solution (Glyceol). METHODS: Sixty-seven consecutive GI tumors in 54 patients who met indication criteria of ESD were enrolled. The mixing ratios of Suvenyl and Glyceol were 1:3 for esophageal/colorectal tumors and stomach tumors with scar, and 1:7 for stomach tumors without scar. After creation of SFCs, mucosal incision around the tumors and submucosal dissection under the tumors were made by cutting devices. The clinical outcomes were investigated. RESULTS: Mean resected and tumor sizes were 38.6 and 25.6 mm, respectively. Perforation occurred in one colon tumor with severe fibrosis (1.5%), which was managed by endoscopic clipping without salvage surgery. No blood transfusion was performed. In one stomach and in one rectal tumor (3%), endoscopic hemostasis was necessary because of postoperative bleeding. Overall endoscopic and histologic en bloc resection rates were 94% (63/67) and 78% (52/67), respectively, and there was no recurrence after follow-up of 1 year. CONCLUSIONS: ESD when using a mixture of Suvenyl and Glyceol results in excellent outcomes, and this injection solution should be used for ESD.     

Endoscopic Clipping with a New Rotatable Clip-Device and a Long Clip

Abstract: We developed a rotatable, highly durable clipping device (rotatable clip-device) and a long clip which can be used to effectively grasp a large bite of tissue. However, application of the long clip required a special reinforced clipping device. The new rotatable clip-device can be appropriately used in combination with the long clip because of its improved strength and rotatability. The rotatable clip-device was used for endoscopic treatment of 133 patients, including 43 requiring hemostasis of gastrointestinal bleeding, 43 with prophylactic clipping following polypectomy, 39 with mucosal closure following endoscopic mucosal resection (EMR), and 10 undergoing prophylactic ligation of esophageal varices. The long clips were used mainly for mucosal closure after EMR. The rotatable clip-device was found to be especially useful for hemostasis of soft bleeding lesions. Prophylactic clipping following polypectomy prevented complications in 40 out of 41 patients. Mucosal closure by means of clipping following EMR prevented complications in all 39 patients, and the rotatability of the rotatable clip-device and the large bite capacity of the long clip greatly facilitated closing mucosal defects, especially large defects. In the 10 patients who underwent prophylactic clipping of esophageal varices, the rotatable clip-device allowed the varices to be grasped securely and ligated effectively. During endoscopic treatment, three of the four clip-devices functioned normally despite frequent auto-claving and clipping procedures.     

Synchronous spontaneous perforation of the esophagus and a duodenal ulcer

SUMMARY: Although 41% of patients with spontaneous rupture of the esophagus also suffer from gastro duodenal ulcer disease, cases of synchronous spontaneous esophageal and duodenal ulcer perforation have thus far not been reported in the literature. We report on the case of a 61-year-old man who presented with a 72-hour history of esophageal rupture and duodenal ulcer perforation. Following appropriate circulatory resuscitation we performed double resection; involving the esophagus, cardia and the distal part of the stomach, followed by substitution by means of gastro-jejunal transposition as a one-stage procedure. With reference to this case with a favorable outcome, we are presenting an analysis of indications for resectional surgery in advanced spontaneous esophageal perforation.     

Endoscopic clip application for closure of esophageal perforations caused by EMR

BACKGROUND: With increasing use of EMR for early stage esophageal carcinoma, the number of cases of iatrogenic esophageal perforation is likely to increase. This study evaluated the results of endoscopic clip application for treatment of perforations caused by EMR in patients with esophageal carcinoma. METHODS: Among 185 patients who underwent EMR for esophageal carcinoma, esophageal perforation occurred in 3 patients (1.6%). Metallic clips were immediately applied endoscopically to close the perforations. OBSERVATIONS: All 3 patients were observed closely and were managed conservatively (intravenous hyperalimentation, antibiotics) after closure of the perforation. They were discharged without any further serious complication. CONCLUSIONS: When esophageal perforation caused by EMR is immediately recognized, endoscopic application of metallic clips is appropriate therapy. However, patients must be carefully monitored for the development of generalized mediastinitis.     

Boerhaave's syndrome as the primary manifestation of adult eosinophilic esophagitis. Two case reports and a review of the literature

Eosinophilic esophagitis (EoE) has been associated with an increased risk of esophageal mucosal tears induced by vomiting to dislodge impacted food or following endoscopic procedures. However, Boerhaave's syndrome or transmural perforation of the organ resulting from vomiting induced to dislodge impacted food has rarely been reported. In this article, we present two male adult patients with long‐term esophageal symptoms who suffered from Boerhaave's syndrome after the impaction of food in the esophagus. Both patients required surgical management because of clinical and radiological signs of perforation. This rare complication of EoE has been documented in 11 other reports, predominantly affecting young men in whom EoE had not been previously diagnosed, despite the majority having esophageal symptoms and a history of atopy. There are only two published cases of esophageal perforation that presented in children, which were managed conservatively. Our two patients and 4 out of the 11 described in literature required surgery because of esophageal perforation. Our two cases involved closure of the perforation, while in three published reports, perforation resulted in a partial or complete esophagectomy. No cases have been published on Boerhaave's syndrome caused by EoE that ended in fatalities. It is important to note that esophageal perforation caused by vomiting is a potentially severe complication of EoE that is being increasingly described in literature. Therefore, patients with non‐traumatic Boerhaave's syndrome should be assessed for EoE, especially if they are young men who have a prior history of dysphagia and allergic manifestations.     

Treatment of chronic contained spontaneous esophageal perforations

Spontaneous esophageal perforations are associated with a high mortality and morbidity without surgery. The treatment mortality for early (<24) and late (>24 h) spontaneous esophageal perforations is reviewed as well as all recent cases of chronic spontaneous esophageal perforations. Chronic esophageal perforations with mediastinal cavities may be best treated by internal drainage of the cavity into the esophagus in order to convert the transmural perforation into an intramural esophageal dissection.     

One hundred and one over-the-scope-clip applications for severe gastrointestinal bleeding,leaks and fistulas

AIM: To investigate the efficacy and clinical outcome of patients treated with an over-the-scope-clip(OTSC) system for severe gastrointestinal hemorrhage, perforations and fistulas.METHODS: From 02-2009 to 10-2012, 84 patients were treated with 101 OTSC clips. 41 patients(48.8%) presented with severe upper-gastrointestinal(GI) bleeding, 3(3.6%) patients with lower-GI bleeding, 7 patients(8.3%) underwent perforation closure, 18 patients(21.4%) had prevention of secondary perforation, 12 patients(14.3%) had control of secondary bleeding after endoscopic mucosal resection or endoscopic submucosal dissection(ESD) and 3 patients(3.6%) had an intervention on a chronic fistula. RESULTS: In 78/84 patients(92.8%), primary treatment with the OTSC was technically successful. Clinical primary success was achieved in 75/84 patients(89.28%). The overall mortality in the study patients was 11/84(13.1%) and was seen in patients with life threatning upper GI hemorrhage. There was no mortality in any other treatment group. In detail OTSC application lead to a clinical success in 35/41(85.36%) patients with upper GI bleeding and in 3/3 patients with lower GI bleeding. Technical success of perforation closure was 100% while clinical success was seen in 4/7 cases(57.14%) due to attendant circumstances unrelated to the OTSC. Technical and clinic success was achieved in 18/18(100%) patients for the prevention of bleeding or perforation after endoscopic mucosal resection and ESD and in 3/3 cases of fistula closure. Two application-related complications were seen(2%).CONCLUSION: This largest single center experience published so far confirms the value of the OTSC for GI emergencies and complications. Further clinical experience will help to identify optimal indications for its targeted and prophylactic use.     

Management of spontaneous perforation of esophageal cancer with covered self expanding metallic stents

Optimal management of esophageal perforation is controversial, especially in the presence of malignancy. Esophagectomy has traditionally been employed for patients with malignant perforations. However, in patients with advanced disease, other less invasive treatment options may be of benefit. We present two cases of spontaneous perforation of advanced esophageal cancer successfully managed by insertion of covered self-expanding metallic stents and a review of the literature.     

Bowel perforation in type IV vascular Ehlers–Danlos syndrome. A systematic review

Spontaneous gastrointestinal (GI) perforation is a well-known complication occurring in patients suffering from Type IV vascular Ehlers–Danlos syndrome (EDS IV). The aim of the present study was to review the current literature on spontaneous GI perforation in EDS IV and illustrate the surgical management and outcome when possible. A systematic review of all the published data on EDS IV patients with spontaneous GI perforation between January 2000 and December 2015 was conducted using three major databases PUBMED, EMBASE, and Cochrane Central Register of Controlled Trails. References of the selected articles were screened to avoid missing main articles. Twenty-seven published case reports and four retrospective studies, including 31 and 527 cases, respectively, matched the search criteria. A case from our institution was added. Mean age was 26 years (range 6–64 years). The most frequent site of perforation was the colon, particularly the sigmoid, followed by small bowel, upper rectum, and finally stomach. The majority of cases were initially managed with Hartmann’s procedure. In recurrent perforations, total colectomy was performed. The reperforation rate was considerably higher in the “partial colectomy with anastomosis” group than in the Hartmann group. Colonic perforation is the most common spontaneous GI perforation in EDS IV patients. An unexpected fragility of the tissues should raise the possibility of a connective tissue disorder and prompt further investigation with eventual management of these high-risk patients with a multidisciplinary team approach in dedicated centres. In the emergency setting, a Hartmann procedure should be performed.     

Endoscopic treatment of duodenal fistula after incomplete closure of ERCP-related duodenal perforation

Endoscopic retrograde cholangiopancreatography(ERCP)is an important diagnostic and therapeutic modality for various pancreatic and biliary diseases.The most common ERCP-induced complication is pancreatitis,whereas hemorrhage,cholangitis,and perforation occur less frequently.Early recognition and prompt treatment of these complications may minimize the morbidity and mortality.One of the most serious complications is perforation.Although the incidence of duodenal perforation after ERCP has decreased to1.0%,severe cases still require prolonged hospitalization and urgent surgical intervention,potentially leading to permanent disability or mortality.Surgery remains the mainstay treatment for perforations of the luminal organs of the gastrointestinal tract.However,evidence from case reports and case series support a beneficial role of endoscopic clipping in the closure of these defects.Duodenal fistulas are usually a result of sphincterotomies,perforated duodenal ulcers,or gastrectomy.Other causative factors include Crohn's disease,trauma,pancreatitis,and cancer.The majority of duodenal fistulas heal with nonoperative management.Those that fail to heal are best treated with gastrojejunostomy.Recently proposed endoscopic approaches for managing gastrointestinal leaks caused by fistulas include fibrin glue injection and positioning of endoclips.Our patient developed a secondary persistent duodenal fistula as a result of previous incomplete closure of duodenal perforation with hemoclips and an endoloop.The fistula was successfully repaired by additional clipping and fibrin glue injection.     

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.