Elsevier

Gastrointestinal Endoscopy

Volume 84, Issue 3, September 2016, Pages 487-493
Gastrointestinal Endoscopy

Original article
Clinical endoscopy
Endoscopic management of colonic perforations: clips versus suturing closure (with videos)

https://doi.org/10.1016/j.gie.2015.08.074Get rights and content

Background and Aims

Perforation during colonoscopy remains the most worrisome adverse event and usually requires urgent surgical rescue. The aim of this study was to evaluate the feasibility and effectiveness of endoscopic closure of full-thickness colonic perforations.

Methods

We performed a retrospective analysis of all consecutive patients with endoscopically closed colonic perforations over the past 6 years (2009-2014). Colonic perforations were closed by using endoscopic clips or an endoscopic suturing device. Most patients were admitted for treatment with intravenous antibiotics and kept on bowel rest. If their clinical condition deteriorated, urgent surgery was performed. If patients remained stable, oral feeding was resumed, and patients were discharged with subsequent clinical and endoscopic follow-up.

Results

Twenty-one patients had iatrogenic colonic perforations closed with an endoscopic suturing device or endoscopic clips during the study period. Primary closure of a colonic perforation was performed with endoscopic clips in 5 patients and sutured with an endoscopic suturing device in 16 patients. All 5 patients after clip closure had worsening of abdominal pain and required laparoscopy (4 patients) or rescue colonoscopy with endoscopic suturing closure (1 patient). Two patients had abdominal pain after endoscopic suturing closure, but diagnostic laparoscopy confirmed complete and adequate endoscopic closure of the perforations. The other 15 patients did not require any rescue surgery or laparoscopy after endoscopic suturing. The main limitation of our study is its retrospective, single-center design and relatively small number of patients.

Conclusion

Endoscopic suturing closure of colonic perforations is technically feasible, eliminates the need for rescue surgery, and appears more effective than closure with hemostatic endoscopic clips.

Section snippets

Methods

We obtained permission from the institutional review board of Mercy Medical Center to perform a retrospective analysis of medical records of consecutive adult patients who had endoscopic closure of documented colonic perforations over the past 6 years (2009-2014).

All patients had undergone screening or therapeutic colonoscopy. Demographic and clinical data including patient age, sex, indications for colonoscopy, pathological diagnosis, lesion size and location, adverse events, and follow-up

Results

From 2009 to 2014, colonic perforations were closed endoscopically in 21 patients (Table 1). In 12 patients, colonoscopies were performed with the patient under deep sedation, whereas in 9, the patients were under general anesthesia.

Primary closure of colonic perforations was performed with endoscopic clips in 5 patients (Fig. 1) and with an Overstitch endoscopic suturing device in 16 patients (Fig. 2).

Patients in both groups (clip closure and endoscopic suturing closure) were similar in age

Discussion

Wider implementation of screening colonoscopy, improved polyp detection, and introduction of more aggressive endoscopic procedures for removal of colonic polyps (EMR and ESD) could cause an increased number of colonic perforations.1, 2, 3, 4, 5, 6, 7 Although previous animal experiments demonstrated the technical feasibility of colonic perforation closure with endoscopic clips and sutures, so far no dedicated clinical study has compared the reliability of various endoscopic techniques for

References (25)

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    These findings further emphasize the utility of both prophylactic and rescue suturing as viable modalities for prevention of delayed post-ESD bleeding, perforation, and overall promotion of mucosal healing. Only a handful of studies have explored the utility of endoscopic suturing in ESD.9,10,14 A retrospective study of 12 lesions (4 gastric and 8 colonic) with a mean size of 42.5 mm demonstrated the technical feasibility and quickness of the technique, with no immediate or delayed adverse events.8

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DISCLOSURE: Dr Kantsevoy is a cofounder of and shareholder in Apollo Endosurgery Inc. All other authors disclosed no financial relationships relevant to this publication.

See CME section; p. 506.

If you would like to chat with an author of this article, you may contact Dr Kantesevoy at [email protected].

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