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Create a Free AccountProcedures - Closure of Perforation/Fistula
Over-the-scope clip to the rescue: solution for duodenal perforation from migrated biliary stent
Iatrogenic perforation of the duodenum caused by biliary stents is a rare adverse event of ERCP.1 While the only available definitive treatment option was previously surgery, the advancement in the minimally invasive endoscopic field led to the development of over-the-scope clips (OTSCs), which allow complete closure of full-thickness defects endoscopically.2Endoscopic pyloric exclusion—EUS-guided gastrojejunostomy combined with endoscopic suturing and closure of the pylorus: a novel approach to failed surgical repair of a perforated duodenal ulcer
An 82-year-old woman with metastatic breast cancer was admitted with an acute abdomen. She was found to have a duodenal bulb perforation, for which she underwent emergent surgical repair using an omental patch. Postoperatively, the patient developed a large-volume enteric output from the Jackson-Pratt drains, and she was found to have a persistent duodenal leak on a CT scan. She was referred to our center in her third postoperative week.Management of an iatrogenic duodenal perforation with a helical tack system in a patient with pancreatic cancer complicated by gastric outlet obstruction
Although endoscopic procedures are safe, they carry a risk of perforation, which can manifest severe adverse events for patients if not managed expediently. Endoscopic methods of closure include clips, injectable agents, and suturing devices.1,2 Occasionally, perforations occur in difficult locations. Recently, a through-the-scope tacking system, X-tack Endoscopic HeliX Tacking System 160 cm (HTS) (Apollo Endosurgery Inc, Austin, Tex, USA), has been made available for mucosal defect closure, providing endoscopists with another tool to manage adverse events.Duodenal stenting as a palliative approach to a malignant duodenocolonic fistula
Duodenocolonic fistulae may result as adverse events of malignancies, and their management is often challenging for nonsurgical patients. Our case demonstrates a palliative approach in the management of malignant duodenocolonic fistula by means of luminal stent placement.Iatrogenic perforation during lumen-apposing metal stent deployment closed using an over-the-scope stent fixation clip device
EUS-guided gastrojejunostomy (EUS-GJ) has emerged as a safe and effective alternative for the palliative management of malignant gastric outlet obstruction.1,2 Although rare, perforation is a known adverse event of EUS-GJ seen in 1.6% of patients.3 We present a case of endoscopic closure of an iatrogenic perforation caused while performing EUS-GJ using an over-the-scope (OTS) stent fixation clip device (Video 1, available online at www.giejournal.org ).Successful management of a duodenal perforation using a through-the-scope suturing device after failed attempt at closure with an over-the-scope clip
The X-Tack Endoscopic HeliX Tacking System (Apollo Endosurgery, Austin, Tex, USA) is a novel through-the-scope suture-based device approved for tissue approximation of mucosal defects. Initial case reports and case series have been encouraging on its efficacy for closure of mucosal defects.1-3 However, this device is not intended for full-thickness closure, and there are limited data on this approach.4,5 In this video, we present the successful use of the HeliX Tacking System for the management of a duodenal perforation after a same-session failed attempt at closure with an over-the-scope clip (OTSC).Endoscopic nasobiliary drainage tube placement through a periampullary perforation for management of intestinal leak and necrotizing pancreatitis
Periampullary perforation has a high mortality rate.1,2 Endoscopic management, including a biliary stent placement into the common bile duct (CBD) and hemostatic clips, can treat the periampullary perforation.3,4 However, it can be difficult to close the perforation and prevent the intestinal juice leakage in the case of the perforation with severe inflammation.Rare solitary giant hamartomatous polyp of the stomach removed by endoscopic submucosal dissection
The incidence of solitary gastric hamartomatous polyps (SGHPs) is extremely low, with fewer than 12 cases reported in the literature.1 Common symptoms include abdominal pain, bleeding, and anemia. While most SGHPs are benign, dysplastic changes have been reported.1,2 Hence, large lesions are typically referred for resection.1 In this video, we present a case of an SGHP resected with endoscopic submucosal dissection (ESD) (Video 1, available online at www.giejournal.org ).Endoscopic rescue of anastomotic dehiscence after urgent gastric bypass revision
Adverse events are rare after bariatric surgery; however, leaks can lead to high morbidity. A large population study demonstrated a rare need for endoscopic management, most commonly endoluminal stent therapy. Unfortunately, many patients eventually needed surgical intervention and patients with stents had a notable rate of readmissions.1 Although stents are a valuable tool, newer technologies have expanded the toolbox to address difficult gastrointestinal adverse events.2,3 We present a challenging case of a gastrojejunal anastomotic disruption in a Roux-en-Y patient after recent urgent surgical revision that was rescued with total endoscopic therapy.Endoscopic management of gastrojejunocolic fistula after endoscopic gastrojejunostomy
Endoscopic ultrasound–guided gastrojejunostomy (EUS-GJ) is an alternative to endoscopic stent placement alone and surgical gastrojejunostomy for the management of gastric outlet obstruction (GOO). Similar technical and clinical success rates have been shown with EUS-GJ and endoscopic stent placement alone with lower rates of reintervention in the EUS-GJ group.1 When compared to the more invasive surgical GJ, EUS-GJ has shown similar rates of clinical success and lower adverse event rates.2,3 Rare EUS-GJ adverse events include perforation, peritonitis, bleeding, stent misdeployment, and migration.Endoscopic submucosal dissection with reinforcement using a laparoscopic approach for a duodenal cavernous hemangioma
Duodenal cavernous hemangiomas are rare; however, when they occur, they may require hemostasis.1 Hemangiomas are classified into cavernous, capillary, or mixed tumors; the cavernous type is the most common.2 Cavernous hemangiomas are defined as congenital benign vascular lesions that are venous malformations. Because cavernous hemangiomas are derived from the submucosa, even minimally invasive endoscopic procedures—such as polyp resection, endoscopic mucosal resection, and argon plasma coagulation—may cause heavy bleeding or perforation.Point blank: an endoscopic retrieval of an extraluminal bullet
A 36-year-old man with no medical history presented with multiple gunshot wounds to the right neck, left axilla, and pelvis. An entry wound in the right buttocks was noted without a corresponding exit wound. A CT scan identified the bullet near the rectum, and a leak from an administered barium enema further demonstrated the location. (Figs. 1 and 2) A laparoscopic diverting colostomy was performed, and advanced endoscopy was consulted for retrieval of the bullet for ballistics and closure of the subsequent rectal defect.Endoscopic tacking system as a novel tissue approximation measure for very large EMR defects
Defect closure post-EMR and endoscopic submucosal dissection (ESD) is recommended to decrease the risk of delayed bleeding and perforation. Current methods of tissue approximation and closure of mucosal defects have their limitations, including restricted maneuverability, need for scope withdrawal, or difficulty in apposing larger defects. Through-the-scope HeliX tacking system (Apollo Endosurgery, Austin, Tex, USA) is a novel tissue apposition device designed to mimic suture closure without the need to withdraw the endoscope or insert bulky devices on the tip of the endoscope.Novel dual-action tissue through-the-scope clip for endoscopic closure
Third space endoscopy, also known as submucosal endoscopy, has continued to evolve and expand as a minimally invasive alternative to surgery for the management of various GI diseases. Safe and effective endoscopic mucosal defect closure during many of these procedures is crucial. Conventional through-the-scope (TTS) clips are the most used devices for defect closure given the familiarity and ease of use.1 However, large mucosal defects can be difficult to close by using conventional TTS clips alone, given the inherent restrictions in clip opening width and inability to approximate large gaps firmly and securely.Endoscopic full-thickness resection with through-the-scope suture closure for gastrointestinal stromal tumor
Gastrointestinal stromal tumors (GISTs) greater than 2 cm are considered for resection.1 Those with muscularis propria (MP) involvement, as seen on endoscopic ultrasound and/or radiology, require full-thickness resection (FTR), surgery, or a combined laparoscopic/endoscopic approach.2 Dedicated endoscopic FTR (EFTR) devices are available but limited to lesions less than 2 cm.3,4 We present a GIST resected by EFTR and through-the-scope suture (TTSS) defect closure (Video 1, available online at www.giejournal.org ).An endoscopic approach to therapy for spontaneous esophageal rupture
Boerhaave syndrome is among the most lethal GI tract disorders with a reported mortality rate of up to 40%.1-3 Spontaneous perforations are caused by sudden intraesophageal pressure elevations leading to transmural injury and subsequent mediastinal inflammation, subcutaneous emphysema, and/or necrosis secondary to spillage of gastric contents. Management was historically surgical, but stable patients may benefit from the reduced morbidity and mortality associated with less invasive percutaneous and endoscopic approaches.Purely endoscopic appendectomy
Surgical/laparoscopic appendectomy requires abdominal wall incisions/punctures that can subsequently cause hernias, pain, and delayed return to work and regular physical activity after surgical/laparoscopic removal of the appendix.1 Natural orifice transluminal endoscopic surgery interventions were often performed with laparoscopic assistance and required advancement of an endoscope into the peritoneal cavity through gastric or vaginal wall with increased risk of infection and abdominal adhesions.Follow-up outcomes of mucosal defect closures after endoscopic resection using a helix tacking system and endoclips
The X-Tack endoscopic HeliX tacking system (Apollo Endosurgery, Austin, Tex, USA) has recently been approved by the Food and Drug Administration and is slowly gaining popularity for the closure of large tissue defects. Despite its increasing use, outcome data of using the X-Tack system for mucosal defect closure after endoscopic resection (ER) are limited. Here, we report the follow-up outcomes of a series of cases that underwent ER and mucosal closure aided by the HeliX tacking system.Persistent gastro-cutaneous fistula closure with tack suture system in the setting of a severe esophageal stricture
A 64-year-old man with a history of metastatic squamous cell carcinoma of the larynx underwent laryngopharyngectomy with good response to adjuvant combination of immunotherapy and chemotherapy. Postoperatively, the patient developed symptomatic esophageal stricture requiring serial sessions of endoscopic dilation, which resulted in improved nutritional status and the removal of a previously placed PEG tube. However, a gastro-cutaneous PEG fistula (GCF) persisted 5 months after PEG tube removal, significantly affecting the patient’s quality of life.Successful D-POEM after failed surgical myotomy and diverticulectomy
Peroral endoscopic myotomy with diverticulotomy (D-POEM) is feasible for management of achalasia with an epiphrenic diverticulum (ED).1-3 In a study of 14 patients with ED and underlying motility disorders with isolated lower esophageal sphincter (LES) POEM, all had postoperative Eckardt score improvement.4 Diverticulotomy is second-line treatment.4-7Successful endoscopic ultrasound-guided nasocavitary catheter drainage of abscess caused by delayed perforation after gastric endoscopic submucosal dissection
Delayed perforation after gastric endoscopic submucosal dissection (ESD) is a rare but serious adverse event often requiring emergency surgery.1,2 Here, we report the use of EUS-guided nasocavitary catheter drainage to treat an intra-abdominal abscess caused by delayed perforation after gastric ESD.If at first you don’t succeed… a complicated course of endoscopic reversal of a gastric bypass
Marginal ulcer remains a common adverse event after Roux-en-Y gastric bypass (RYGB). Despite treatment with antisecretory therapy, up to a third of patients with recalcitrant ulcers may require surgical revision.1-4 In suboptimal surgical candidates or in patients who have failed attempts at surgical intervention, endoscopic techniques may be a preferable or required approach. Case reports have described uncomplicated endoscopic bypass reversal to treat refractory marginal ulcers.5 Here, we describe a more complicated, protracted case of a refractory marginal ulceration requiring endoscopic reversal, highlighting the potential for an oscillating, yet salvageable, approach (Video 1, available online at www.giejournal.org ).Endoscopic through-the-scope suturing
There is growing interest in closure of larger mucosal defects, given the increasing use of endoscopic resection for early GI neoplasia and the advent of submucosal endoscopy, including peroral endoscopic myotomy. Existing closure methods include through-the-scope clips, over-the-scope clips, and over-the-scope suturing. Although over-the-scope clips and over-the-scope suturing allow closure of large defects, both require endoscope removal for device application and may have difficulty in treating lesions in the proximal colon or the small intestine.Prophylactic appendiceal retrograde intraluminal stent placement (PARIS)
EMR or endoscopic submucosal dissection (ESD) are highly effective methods for resecting colonic polyps1-4 but are ineffective when removing polyps arising from the appendiceal orifice. Endoscopic full-thickness resection (EFTR) using the full-thickness resection device (FTRD; Ovesco, Tuebingen, Germany) is a favorable approach for the management of such lesions because it overcomes the potential risk of perforation or incomplete resection by deployment of an over-the-scope clip (OTSC) beneath the polyp before resection.Use of a novel helical tack system for the management of challenging upper gastrointestinal defects
Increasingly, gastroenterologists are being asked to assist in the closure of defects. Although there are several available tools that can be used for defect closure, there remains a need for devices that are easy to use, effective, and durable. The aim of this case series is to demonstrate the use of a novel helical tack system in the closure of upper GI defects.
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