Endoscopic treatment of gastric perforation caused by acute necrotizing pancreatitis using over-the-scope clips: a case report

Gastric perforation is a rare complication after acute necrotizing pancreatitis. We describe endoscopic closure of a gastric perforation that appeared 4 days after surgical necrosectomy including splenectomy due to necrotizing pancreatitis, using the over-the-scope clip (OTSC) system (Ovesco Endoscopy GmbH, Tübingen, Germany). The clips, which are made of nitinol, are loaded onto an application cap which is mounted on the distal tip of the endoscope. The lesion was closed with two clips and the patient recovered well without reinterventions. The lesions showed normal healing on follow-up.     

"Sparing the surgeon": clinical experience with over-the-scope clips for gastrointestinal perforation

With increasingly advanced therapeutic endoscopic procedures and more complex gastrointestinal surgery, endoscopists are more often confronted with perforations, fistulas, and anastomotic leakages for which nonsurgical closure is desired. The over-the-scope clip (OTSC) is a novel endoscopic tool for consideration in such situations. We treated seven patients (age range 35?-?83 years; five men, two women), three with colonic perforation, one with perforation of the stomach, and three with anastomotic leakage after gastrointestinal surgery. Follow-up was at least 74 days. Eight OTSCs were deployed. In all but one patient closure of the perforation was demonstrated. Further surgery was avoided in four of the seven patients. The OTSC is a system that is easy to handle and safe. It seems to be ideally suited to use for a relatively small (iatrogenic) perforation, where a single clip can be released with carbon dioxide insufflation. Anastomosis leakage and larger dehiscence can also be treated to avoid further surgery, but the utility in this situation needs to be defined in the future.     

Submucosal endoscopy, a new era of pure natural orifice translumenal endoscopic surgery (NOTES)

Natural orifice translumenal endoscopic surgery (NOTES) involves the intentional perforation of the viscera with an endoscope to access the abdominal cavity and perform an intraabdominal operation. In a brief time period, NOTES has been shown to be feasible in laboratory animal and human studies. Easy access to the peritoneal cavity and complete gastric closure should be secured before NOTES can be recommended as an acceptable alternative in clinical practice. The concept of submucosal endoscopy has been introduced as a solution to overcome these two primary barriers to human NOTES application. Its offset entry/exit access method effectively prevents contamination and allows the rapid closure of the entry site with a simple mucosal apposition. In addition, it could be used as an endoscopic working space for various submucosal conditions. Herein, the detailed procedures, laboratory results and human application of the submucosal endoscopy will be reviewed.     

OTSC金属夹在封闭急性医源性消化道穿孔中的临床应用

目的评估内镜下Over-The-Scope-Clip system(OTSC)金属夹闭合医源性消化道穿孔的效果。方法对OTSC夹闭的11例急性医源性消化道穿孔病例进行了回顾性分析。其中,胃穿孔7例,十二指肠穿孔1例,结直肠穿孔3例。结果 11例患者均及时成功地进行了内镜下OTSC封闭,平均内镜下封闭术所需时间为6~15 min,封闭穿孔直径0.6~3.7 cm。结论内镜下OTSC夹闭术对急性医源性消化道穿孔疗效可靠,值得推广使用。     

OTSC金属夹治疗难治性急性非静脉曲张性上消化道出血的效果评估

目的探讨内镜下OTSC金属夹闭合术在难治性急性非静脉曲张性上消化道出血(ANVUGIB)治疗中的疗效。方法对滨州医学院附属医院消化内科2015年1月1日-2016年6月1日通过OTSC金属夹治疗的16例难治性ANVUGIB的患者进行回顾性分析。其中贲门黏膜撕裂并出血2例,胃溃疡出血7例,胃癌1例,十二指肠球部溃疡出血6例。结果 16例患者均成功的进行了内镜下止血,成功率100.0%,止血夹自安装至释放成功平均所需时间仅为5.0~6.0 min。结论 OTSC在难治性ANVUGIB患者中的治疗安全、有效,值得临床推广。     

Establishment of pure NOTES procedure using a conventional flexible endoscope: review of six cases of gastric gastrointestinal stromal tumors

An increasing number of reports have recently been published on hybrid natural orifice transluminal endoscopic surgery (NOTES). These reports do not address how to complete an operation with a flexible endoscope alone (pure NOTES), but rather how to combine use of an endoscope and a laparoscope. Surgical procedures using flexible and rigid endoscopes have been developed using different processes and concepts. Recognizing this conceptual difference, we conducted a study to address how to establish a pure NOTES procedure. Six patients with gastric gastrointestinal stromal tumors (GISTs) underwent hybrid NOTES. Each case was retrospectively reviewed to determine the appropriateness of the treatment and the usefulness of the endoscopic submucosal dissection (ESD) method, double-scope method, spaced perforation method, duodenal balloon occlusion method, and loop clip technique. The development of operative procedures that take advantage of the characteristics of flexible endoscopes, even with conventional flexible endoscopic devices and conventional endoscopes alone, may contribute to the realization of pure NOTES.     

Techniques for transgastric access to the peritoneal cavity

Natural orifice translumenal endoscopic surgery (NOTES) is a unique emerging surgical concept expanding flexible endoscopy beyond the gut wall. The methods and technology growing from this concept may minimize trauma from surgical access to the peritoneal cavity by completely eliminating body surface incisions. So far, NOTES surgeries have been reported by modifying laparoscopic surgery. The peroral transgastric route was chosen to access the peritoneal cavity in initial trials because of a potentially lower risk for surrounding organ injury using the anterior wall percutaneous endoscopic gastrostomy-style gastrotomy. This article reviews and describes techniques of transgastric access to the peritoneal cavity used in published animal studies.     

Feasibility of fibrin glue versus endoclips to close the transgastric peritoneal access site in NOTES in a survival porcine study

Introduction: Safe peritoneal access and gastric closure are the most important concerns in clinical applications of NOTES. Our past study demonstrated usefulness of the submucosal tunnel technique for safe peritoneal access and closure with endoclips. However, such closure is sometimes difficult and time‐consuming. This study investigated the feasibility of fibrin glue for submucosal tunnel closure in a NOTES porcine model. Methods: In 10 female pigs each weighing 40 kg, transgastric peritoneoscopy was performed through a 60 mm‐long submucosal tunnel created using the endoscopic submucosal dissection technique. After transgastric peritoneoscopy for 30 min, the submucosal tunnel was closed with endoclips in five pigs and fibrin glue in five pigs. After a 7 d follow‐up period, the pigs were euthanized for post‐mortem examination. Outcome measures included (a) technical feasibility of closure with endoclips versus fibrin glue, (b) clinical monitoring for 7 d, (c) follow‐up necropsy at 7 d, and (d) histopathologic examination of the peritoneal access site. Results: Transgastric peritoneoscopy with submucosal tunnel technique was successful in all pigs. Mean time required to close the mucosal incision site with fibrin glue was 1.6 ± 0.5 versus 19 ± 18.7 min with endoclips. All pigs survived well without complications. Necropsy revealed no peritonitis. There were no differences in transgastric peritoneal access sites between endoclips and fibrin glue. Histopathologic examination of the submucosal tunnel demonstrated wound healing with transmural fibrosis. No adverse effects from fibrin glue were noted. Conclusion: Compared with endoclips, the application of fibrin glue is easy and simple in the closure of transgastric peritoneal access in NOTES.     

The OTSC? Proctology clip system for anorectal fistula closure: the 'anal fistula claw': case report

Abstract Surgical treatment of high or complex anal fistulas often renders unsatisfying results. This is the report of the first successful closure of such anal fistula using a special Nitinol clip and applicator, the OTSC? Proctology system (Ovesco AG, Tuebingen, Germany): A 54-year old female patient was suffering from a high transsphincteric anal fistula. After seton drainage of the fistula for ten weeks, the fistula track was debrided using a special fistula brush. After transanal clip release from the applicator, the internal fistula opening was adequately closed by the clip. Eight months after clip closure the fistula had healed and the clip was removed using the OTSC? Proctology Clip Cutter. Fistula closure using the OTSC? Proctology system represents a promising sphincter-preserving minimally invasive procedure.     

Endoscopic repair of delayed stomach perforation caused by penetrating trauma: A case report

BACKGROUNDPrimary endoscopic closure of a perforated gastric wall during endoscopic procedures is mostly effective and well-tolerated; however, there are very few studies on the efficacy of endoscopic management of delayed traumatic gastric perforation. Herein, we report a novel case of a patient who was successfully treated for delayed traumatic stomach perforation using an alternative endoscopic modality.CASE SUMMARYA 39-year-old woman presented with multiple penetrating traumas in the back and left abdominal cavity. Initial imaging studies revealed left diaphragmatic disruption and peri-splenic hemorrhage without gastric perforation. An emergency primary repair of the disrupted diaphragm with omental reduction and suturing of the lacerated lung was performed; however, delayed free perforation of the gastric wall was noted on computed tomography after 3 d. Following an emergency abdominal surgery for the primary repair of the gastric wall, re-perforation was noted 15 d postoperatively. The high risk associated with re-surgery prompted an endoscopic intervention using 2 endoloops and 11 endoscopic clips using a novel modified purse-string suture technique. The free perforated gastric wall was successfully repaired without additional surgery or intervention. The patient was discharged after 46 d without any complications.CONCLUSIONEndoscopic closure with endoloops and clips can be a useful therapeutic alternative to re-surgery for delayed traumatic gastric perforation.     

Endoluminal full-thickness resection of GI lesions: A new device and technique

Abstract

Full-thickness resection techniques are of growing interest in the field of endoscopic removal of tumors or their precursors in the digestive tract. A new dedicated full-thickness resection device has been developed based on the combination of the OTSC clip, an enlarged resection cap and an integrated snare. The device prototype allows combined resection of all gastrointestinal organ wall layers in one maneuver, up to a size of 3 x 3 cm. The device has been pre-clinically tested to demonstrate feasibility of full-thickness resection in the colon. Two clinical cases have been performed successfully to date.     

Flexible endoscopic robot

Natural orifice transluminal endoscopic surgery (NOTES) is a novel surgical procedure during which abdominal operations can be performed with an endoscope passed through a natural orifice through an internal incision in the stomach, vagina, bladder or colon. NOTES is still evolving and many barriers stand on its way before it can gain acceptance in modern surgical practice. Effective access to the peritoneal cavity, closure techniques of the natural orifice access sites, development of a multitasking platform to accomplish procedures and support for special orientation are only a handful of its known limitations. Although the endoscope and conventional tools are useful for simple procedures, many important and complicated procedures are currently not possible due to limitation of degree of freedom (DOF) of the end effectors. We have developed a Master and Slave Transluminal Endoscopic Robot (MASTER) with nine degrees of freedom (DOF) in end effectors, which are long and flexible so as to enhance endoscopic procedures and NOTES. Using MASTER we have successfully performed endoscopic sub-mucosal dissections (ESD) to segmental hepatectomies in animal models. Thus, the MASTER robotic system shows great potential to perform new surgical procedures that are otherwise not possible with conventional endoscopic tools.     

Development of advanced endoscopes for Natural Orifice Transluminal Endoscopic Surgery (NOTES)

Natural orifice transluminal endoscopic surgery (NOTES) is a hybrid procedure which uses flexible endoscopic technology to perform laparoscopic surgical procedures within the abdominal cavity. Initial reports of animal studies describe the use of standard endoluminal endoscopes to accomplish intra‐abdominal surgeries. Current flexible scopes suffer from several deficiencies which make them unlikely to be able to be used for large scale human NOTES experiences. This review analyzes the deficiencies of current endoscopes, discuses the requirements of the ideal NOTES endoscope and reviews some of the possible “endoscopes of the future” that are being developed for the next generation of surgery. Discussion focuses on the “R” scope (Olympus, Tokyo, Japan) and the Transport and Cobra scopes (USGI Medical, San Capistrano, CA).     

Endoscopic treatment of gastrointestinal fistulas using an over-the-scope clip (OTSC) device: case series from a tertiary referral center

Gastrointestinal perforations and post-surgical fistulas are dreaded complications that dramatically increase morbidity and mortality. A new endoscopic over-the-scope clip (OTSC) system may be potentially useful for sealing visceral perforations in several clinical settings. We evaluated the advantages and clinical impact of the placement of OTSCs on the management of non-malignant gut leaks in 12 consecutive patients. OTSCs of 9.5 or 10.5 mm were used, according to the diameter of the defect within the wall. The indications for treatment were mainly related to post-surgical fistulas. Healing of the fistula was assessed by endoscopic or radiological means, and failed only once. No OTSC-related complications occurred. Endoscopic closure of perforations and post-surgical fistulas with the OTSC system is a simple and minimally invasive technique. This approach, when feasible, may be less expensive and more advantageous than a surgical approach.     

Use of omental patch and endoscopic closure technique as an alternative to surgery after endoscopic full thickness resection of gastric intestinal stromal tumors: A series of cases

BACKGROUND Gastrointestinal stromal tumors(GISTs)originate from interstitial cells of Cajal.GISTs can occur anywhere along the gastrointestinal tract.Large lesions have traditionally been removed surgically.However,with recent innovations in advanced endoscopy,GISTs located within the stomach are now removed endoscopically.We describe a new innovative endoscopic technique to close large and hard to access defects after endoscopic full-thickness resection of gastric GISTs.CASE SUMMARY We present a series of three patients who were diagnosed with a gastric GIST.All patients underwent full-thickness endoscopic resection.In all cases,for closure of the surgical bed,conventional endoscopic techniques including hemoclips,endoloop and suturing were unsuccessful.We performed a new technique in which we pulled omental fat into the gastric lumen and completely closed the defect using endoscopic devices.All patients performed well post-procedure and computed tomography was carried out one day after the procedures which showed no extravasation of contrast.CONCLUSION The omental plug technique may be used as an alternative to surgery in selected cases of gastric perforation.     

Performance of the OTSC System in the endoscopic closure of gastrointestinal fistulae - a meta-analysis

Abstract

Background: Conventional endoscopic treatment options for closure of gastrointestinal fistulae are impaired by several limitations and therefore yield high rates of recurrence. Aim of the study is the evaluation of the primary-technical and secondary-clinical success rates in closure of gastrointestinal fistulae by means of the OTSC System. Design/Methods: The database Medline was systematically searched for primary research on the evaluation of the OTSC System in closure of gastrointestinal fistulae. Appraisal of studies for inclusion and data extraction were performed independently by two reviewers using an a priori determined data extraction grid. Results: A total of 19 primary research articles were identified. The examined studies comprised case reports as well as case series and clinical single-arm studies (n = 7) with a limited number of participants. Reviewed studies revealed a high rate of procedural success (mean 84.6%; 95% confidence interval 66.6 to 93.8%) and durable clinical success (mean 69.0%; 95% confidence interval 51.8 to 82.2%). Failed attempts and incomplete closures were mainly ascribed to the challenging effort of treating highly fibrotic chronic fistulae. Conclusion: Endoscopic closure of gastrointestinal fistulae by means of the OTSC System is a safe and effective method.     

NOTES: a surgeon's perspective

Natural orifice transluminal endoscopic surgery (NOTES) is an exciting concept gaining national attention as a novel and minimally invasive approach to gastrointestinal surgery and endoscopy. The hope of combining the talents and experience of surgeons and gastrointestinal endoscopists with emerging technologies has created enthusiasm for developing this approach as a specialty itself. Upon initial review, many procedures seem to naturally lend themselves to this approach and include endoscopic mucosal resection, small tumor excision, and access to the peritoneum. The main question to be answered in this short article is: What is gained and what is lost with NOTES?     

Techniques for transanal access to the peritoneal cavity

Natural orifice translumenal endoscopic surgery (NOTES) represents a burgeoning but still largely experimental field. For surgeries involving the upper abdominal organs, the transanal approach promises to provide a more direct route in contrast to the often cumbersome retroflexion typically required with the transgastric approach. The potential disadvantages of the transanal route are also significant and include issues of sterility, the risk of inadvertent trauma to adjacent organs during transmural puncture, and the risk of colonic wall shearing. This article reviews the evolution of transanal access to the peritoneal cavity, highlights the various techniques that have been used for transanal access and closure, and discusses in further detail the relative advantages and disadvantages of this approach.     

NOTES: the future

The concept of natural orifice translumenal endoscopic surgery (NOTES) has grown in acceptance since the time of its introduction in 2000. Developments in techniques of peritoneal access and closure, surgical techniques, and equipment modification have already been published and intensive research is ongoing. Current and future endoscopists will reap the benefit of this research because many techniques and devices that are developed for NOTES will enhance the ability to perform luminal intervention, including polypectomy, endoluminal hemostasis, and submucosal resection. The authors attempt to predict the future of NOTES by describing potential applications for certain clinical scenarios and conditions.     

消化道无蒂隆起性病变的内镜黏膜切除术和内镜黏膜下剥离术治疗分析

目的探讨内镜下粘膜切除术(EMR)和内镜粘膜下剥离术(ESD)治疗消化道无蒂隆起性病变包括早癌的疗效和安全性。方法对行EMR和ESD的43例消化道无蒂隆起性病变患者做回顾性分析。结果 43例无蒂隆起性病变食管11例,胃底4例,胃体8例,胃窦8例,贲门11例,直肠1例。EMR32例,ESD 11例。EMR病变长径、手术时间均明显低于ESD;EMR术后1例出血,无穿孔,ESD术后1例出血,2例穿孔,皆保守治疗后治愈。术后病理提示间质瘤6例,息肉23例,1例异位胰腺,7例上皮内瘤变,6例早癌。基底和切缘均未见病变累及。术后2月、6月随访,创面愈合,无病变残留和复发。结论 EMR和ESD治疗消化道无蒂隆起性病变安全有效,可以提供完整的病理诊断学资料。EMR和ESD可用于治疗消化道早癌。