ABBREVIATIONS
CT
computed tomography
EMR
endoscopic mucosal resection
ESD
endoscopic submucosal dissection
OTS
over-the-scope-closure or clip
TTS
through-the-scope-closure or clip
INTRODUCTION
Advances in endoluminal closure technology during the last two decades permit us to close superficial and deep defects after endoscopic resection techniques, including inadvertent perforations as well as chronic fistulas, and avoid the need for surgery. Endoscopic closure of colon perforations has revolutionized endoluminal surgery. A variety of clips and suturing devices accomplish this feat—these devices allow us to close perforations immediately, thereby eliminating the need for surgery and the morbidity and mortality associated with it. In this chapter, we review the literature on the closure of endoscopy and surgery-associated colonic defects and present some insights on applying this knowledge in clinical practice.
HISTORY
It is interesting to note that endoscopic closure of gastrointestinal perforations started in an endoscopy lab in the 1990s with a couple of case reports, followed by a series of animal laboratory experimental studies that defined its role in the management of colon perforations and widespread application in clinical practice. Professor Nib Soehendra’s team from Hamburg, Germany, utilized clips to close a gastric perforation after the endoscopic resection of a leiomyoma in the 1990s. Later, Hiroaki Yoshikane and his colleagues reported successful clip closure of colon endoscopic mucosal resection (EMR)-related perforation, and Mana and his colleagues reported closure of mechanical perforation of the sigmoid colon. , These studies provided an impetus for subsequent animal studies to explore the application of endoluminal closure devices in the management of colonoscopic perforations and the explosion of the closure devices available to the endoscopist.
ENDOLUMINAL CLOSURE TOOLS
A number of devices are currently available in the US market for defect closure ( Figs. 12.1 and 12.2 ; Table 12.1 ). These devices can be delivered through the endoscope channel (through-the-scope [TTS] devices) or mounted over the endoscope (over-the-scope [OTS] devices), each with some pros and cons. Through-the-scope closure devices can be deployed through the endoscope without leaving the operating field; thus they can be utilized immediately after recognition of perforation to close the defect. OTS devices can close defects larger than those that can be closed by the TTS. However, over-the-scope devices require the removal of the endoscope from the perforation site to load the device onto the end of the endoscope, reinsertion of the endoscope, followed by the closure of the perforation.
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ANIMAL LABORATORY EXPERIMENTAL STUDIES
Currently, available closure devices in the market include through-the-scope clips, over-the-scope clips, and suturing devices; in addition, there is substantial interest in exploring novel options. Experiments have involved the study of colon perforation closure in the porcine colon models.
Through-the-Scope Clips
A series of experimental studies in porcine colon perforation models established the role of endoluminal clip closure of colon perforations. In these studies, through-the-scope clip closure of 1.5 to 2.0 cm linear colonoscopic perforation: (1) resulted in healing of perforation and prevented peritonitis , ; (2) achieved leak-proof sealing of both linear and circular colon perforations , ; (3) produced results comparable to hand-sewn colostomy closure in ex-vivo porcine colon model ; and (4) limited peritoneal adhesions compared to surgical closure in a randomized controlled porcine survival study, given the fact that surgery requires damage to the peritoneum to reach the perforation site for closure. However, gaping perforations with sloping edges could not be successfully closed by through-the-scope clips, although they could be closed by endoluminal suturing devices.
Over-the-Scope Clips
Experimental studies confirmed that over-the-scope clips produce results comparable to hand-sewn colostomy closure in ex-vivo porcine colon model and provide successful defect closure following endoscopic full-thickness resection.
Endoscopic Suturing
The over-the-scope suturing device allows successful closure and healing of colonoscopic perforations in live porcine models. , Through-the-scope suture closure allows successful closure of gaping wide perforations that cannot be closed by TTS as well as full-thickness resection defects of the colon. , The endoscopic hand-suturing technique using a through-the-scope needle holder and an absorbable barbed suture attached to a curved needle, similar to the surgical hand-suturing technique has been studied in animal models involving the stomach.
Collagen Solution
In a series of animal experiments, a novel temperature-responsive, biodegradable, and injectable collagen solution as a closure agent for 3 to 5 mm colonic perforations appeared effective and promising.
ENDOSCOPIC CLOSURE TECHNIQUES
Depending on the type of defect, one could choose the most appropriate tool and technique to close a defect or a perforation. These could be categorized as basic clip closure techniques, where a clip is used to close the defect by opening and closing the clip; and advanced clip closure techniques, where adjuvant techniques are utilized to enhance clip closure of larger defects that cannot be closed with simple closure techniques.
BASIC CLIP CLOSURE TECHNIQUES
Either transverse or longitudinal perforation closure techniques can be utilized for perforation closure depending on the orientation of the defect.
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Longitudinal perforation closure: this technique is useful for the closure of long and linear perforations that extend along the length of the colon. Start at the top end of the perforation and apply the clip just above the upper end of a longitudinal perforation to pucker the edges below for easier application of subsequent clips. Clips are placed from the top down to close longitudinal perforations starting away from the endoscope and working toward the endoscope or left to right for closure of circular or transverse perforations. ,
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Transverse perforation closure: this technique is useful for the closure of small and circular defects. Once the clip is opened, rotate the blades to align them perpendicular to the defect and engage the lower blade to the lower edge of a transverse perforation. Then, gently push the clip–endoscope unit while applying a gentle suction to collapse the lumen so that the opposite edge of the perforation can be grasped as deeply as possible while the clip is slowly closed. ,
CHOOSING THE RIGHT CLIP
Depending on the type of defect encountered, one should choose a clip best suited to the clinical problem, whether it is fine control of rotation, precision in opening and closing, compression, and deployment success. When access to perforation is difficult, choosing a clip with the best rotatability makes sense; Resolution 360 fits this bill. If the precise open and close function is critical to deal with limited operating space, the SureClip and Dura Clip are preferable. To close a gaping perforation, selecting a clip with a good tensile strength that can generate enough force for anchoring and moving one edge to the other edge will be useful; the Quick Clip Pro ranks high in this category. Instinct and Resolution 360 scored high in deployment success. Although each clip may offer unique advantages, the single best clip is the clip most familiar and confident to both the endoscopist and assistant.
PRINCIPLES FOR CLIP CLOSURE AND PRACTICAL TIPS
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Prompt clip closure of colon defects avoids spillage of colon contents into the peritoneal cavity. This may require keeping a couple of clips ready, especially during high-risk resections.
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Maneuver clip–endoscope as a single unit by keeping the clip close to the end of the endoscope; this offers a technical advantage for successful closure.
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Use a distal attachment cap for high-risk cases: routine use of a distal attachment cap allows the endoscopist to deflect the clips and facilitate endoscope passage to reach the defect to close it. In addition, since the current clips have a reopening function, one could negotiate through an area crowded by prior clips with the clip in the closed position and then apply it.
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Place the first clip slightly away from the edge in order to tent the edges of the defect and permit deeper tissue approximation with subsequent clip applications. This technique is also known as the “zipper closure.”
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Apply clips at close quarters to create a leak-proof sealing.
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Compensate for retraction of clips with clip closure by the gentle push of the clip as the blades close. This can be accomplished by either gently pushing the endoscope or clipping the catheter forward while slowly closing the clip ( Figs. 12.3 and 12.4 ).
Fig. 12.3
Through-the-scope clips retract during closure resulting in superficial closure (A–C)
(Reproduced with permission from Gottumukkala S. Raju, University of Texas MD Anderson Cancer Center, Houston, Texas).
Fig. 12.4
Compensate clip retraction during closure either by pushing the endoscope or the clip for a deep approximation of the defect with clips (A–C)
(Reproduced with permission from Gottumukkala S. Raju, University of Texas MD Anderson Cancer Center, Houston, Texas).
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Aim for a deep approximation of the edges of perforation with clip closure and document deep closure by the absence of any visible space between the blades of the clips, which is critical for a leak-proof sealing.
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Compensate for loose approximation of the edges (loose clip as evidenced by obvious space between the blades of the clip) by applying additional clips on either side of that clip to achieve a deep approximation of the defective edges.
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Visualize and photodocument clip closure on both sides of the closure, both front side and back side because sometimes the clip may slip and hang on just the front edge while missing the back edge. Take multiple photos to document it.
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Decompress the colon after defect closure and avoid disruption of clip closure with bowel distention; avoid the temptation of examining the rest of the colon. In addition, while gas escapes through a free perforation does not generally increase the risk of infection, gas insufflation should be limited during repair to prevent mechanical complications from distention, including abdominal compartment syndrome and tension pneumothorax. The abdomen should be monitored for distention during the repair of free perforation.
ADVANCED CLIP CLOSURE TECHNIQUES
Advanced clip closure techniques use additional devices to facilitate clip closure of larger defects ( Fig. 12.5 ). A dual-channel therapeutic endoscope is needed for some of these techniques.
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Hold-and-drag closure technique using repositionable clips: by grasping and dragging the anal edge to the oral side with a larger wingspan clip, both edges can be brought together followed by closing the defect by reopening and placing the clip across both edges; then additional clips are placed to close the remaining defect with either a large wingspan clip or standard clips depending on the size of the defect.
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Closure technique with small mucosal incisions to anchor the clip: the defect is closed with clips by hooking the small incisions and dragging the mucosal layer from one side to the other.
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Endoloop + TTS clips (King closure): an endoloop is delivered through one channel of the endoscope. TTS clips are used to clip the endoloop to the defect circumferentially, followed by tightening of the endoloop to close the defect.
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An 8-ring in combination with clips: after the placement of the first clip with an 8-ring, the second clip hooking the 8-ring is placed on the contra-edge.
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Clip-assisted closure using a foreign body forceps: a large foreign body forceps is passed through one channel of the therapeutic scope and the edges of the defect are approximated followed by the use of a TTS clip through the other channel to close the defect.
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String clip suturing method: the mucosal edges are approximated by pulling the string which is anchored to both edges with clips. The clip with string is applied to the distal edge of the defect, and the second clip hooked on the string is placed on the opposite side. Pulling the string brings the edges of the defect closer for a third clip application across both edges to secure the closure. After the defect is closed, the extra suture is cut with endoscopic scissors.
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String-clip-knotter suturing method: the first clip with the suture thread attached to the clip blade is applied to one edge of the perforation; the free end of the suture thread is passed through a hole in the blade of the second clip, and the clip is applied to the opposite edge of the perforation. A knotter is inserted over the suture thread to the second clip, pulling the thread to bring the defective edges together. Deployment of the knotter both ties and cuts the excess thread.
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Omental patch closure method: the omentum is visualized through an open perforation and suctioned into the lumen before being grasped by clips and secured to the colonic mucosa, thus creating an omental patch. This technique is an extension of the surgical Graham patch utilized for the closure of peptic ulcer perforations. Caution should be exercised in utilizing suction to close full-thickness perforations, especially in the colon, since it risks entrapment of adjacent organs including the small bowel and ureter.
Related posts:
Endoscopy-Associated Complications in Colorectal Diseases: Clinical Presentation and Diagnostic Evaluation
Anastomoses and Complications in Inflammatory Bowel and Colorectal Diseases
Endoscopic Therapy of Fistulas from Chronic Anastomotic Leaks
Stoma Complications: Surgical Management
Corrective Surgery for Surgery-Associated Vaginal Fistula
Stomal Complications: Endoscopic Therapy
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