Review ArticleEndoscopic treatment of iatrogenic gastrointestinal perforations: An overview
Introduction
Recent advances in interventional endoscopy have provided an alternative to surgery by affording a minimally invasive approach in selected patients. However, some of these procedures carry a risk of iatrogenic perforation (IP). Traditionally, treatment of IP has been limited to surgical management or to medical observation; fortunately, many of these complications can now be treated safely and effectively with endoscopy.
Iatrogenic perforation can often be recognized during the endoscopic procedure itself, either by direct visualization of the adjacent organs, or by sudden loss of lumen distension despite insufflation. Closing the perforations, which appear secondary to endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD), is often simpler than those which occur during diagnostic endoscopy, as the latter result from blunt trauma and are often too large to be treated endoscopically [1]. It is advisable to carry on the endoscopic repair immediately in order to prevent peritoneal contamination.
Endoscopic techniques, such as clipping, stenting, suturing, stapling, and combining clips with loops and glue, have been described in the literature.
The aim of this article is to review the available data on endoscopic closure of IP, focusing on their incidence, mechanisms, and risk factors, trying to suggest step-up algorithms of endoscopic treatment, followed, in the case of failure, by timely surgical management. Nevertheless, most endoscopic treatments are the result of anecdotal reports, case series or pilot studies; thus, a cautious approach is warranted until further evidence-based support is provided.
Section snippets
Incidence, mechanisms, and physiopathology
It is difficult to establish true figures regarding the incidence, mortality, and morbidity of IP because of the tendency to under-report complications.
The incidence of perforation in diagnostic gastroscopy is around 0.03% with a mortality rate of 17% and a morbidity rate of 40% [2], [3]. When interventional procedures are included, this ratio ranges between 0.5 and 5% in EMR [4], [5], 4 and 4.8% in ESD [5], [6], while it reaches 2.2% in esophageal dilation [7].
As for colonoscopy, the
Therapeutic means
Shifting insufflation to carbon dioxide (CO2), instead of air, has been shown to benefit in decreasing abdominal pain and discomfort after colonoscopy [26]. It also helps to reduce postprocedural mediastinal emphysema in patients undergoing esophageal ESD, since the esophagus is devoid of serosa [27]. Advantages of using carbon dioxide insufflation have also been demonstrated in prolonged upper gastrointestinal procedures, and when perforation is discovered during therapeutic endoscopy, in
Suggested closure method for different gastrointestinal segments
The following methods have been described in the literature to close IP endoscopically; however, most of them are based on case series and animal studies. Further large prospective trials are needed to evaluate safety, ease of use, cost effectiveness, and risk benefit of these procedures.
Discussion
Most data about the endoscopic closure of IP are case reports and small retrospective series with a bias toward publishing technically successful cases. Very rarely, prospective studies are conducted on animals, but they include a small number of individuals (pilot studies). Since it is very difficult to carry out controlled trials to compare surgical and endoscopic management, the latter can be considered in selected cases, provided strict rules are followed.
Two entities must be
Conclusion
Iatrogenic perforations are serious complications that are possible to manage endoscopically in certain circumstances. Extensive endoscopic knowledge, a highly trained endoscopy team, and the availability of adapted equipments are required to ensure safe closure of the perforation. Moreover, close collaboration with the surgical team is emphasized, even after a successful endoscopic repair.
In the esophagus, immediate identification of the perforation site and stable hemodynamics are necessary
Conflict of interest statement
We certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript.
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