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Revista Española de Enfermedades Digestivas

Print version ISSN 1130-0108

Rev. esp. enferm. dig. vol.104 n.10 Madrid Oct./Nov. 2012

http://dx.doi.org/10.4321/S1130-01082012001000009 

CLINICAL NOTE

 

A novel system for endoscopic closure of iatrogenic colon perforations using the Ovesco® clip and omental patch

Novedoso sistema de cierre endoscópico de una perforación yatrogénica de colon mediante clip Ovesco® y parche de epiplón

 

 

Pilar Díez-Redondo1, José Ignacio Blanco2, Sara Lorenzo-Pelayo1, Carlos de-la-Serna-Higuera1, Paula Gil-Simón1, Noelia Alcaide-Suárez1 and Manuel Pérez-Miranda1

1Department of Gastroenterology. Unit of Endoscopy and 2General Surgery. Hospital Universitario Río Hortega. Valladolid, Spain

Correspondence

 

 


ABSTRACT

The growing endoscopic activity, both diagnostic and therapeutic, are also globally makes frequent endoscopic complications, perforation being one of the most serious. However, we also have more possibilities for endoscopic resolution of iatrogenic caused. We report the case of a sigmoid perforation during a colonoscopy that was resolved satisfactorily, avoiding surgery, by endoscopic closure with a nitinol clip Ovesco®.

Key words: Iatrogenic perforation. Colonoscopy. Ovesco®. Nitinol clip.


RESUMEN

La cada vez mayor actividad endoscópica, tanto diagnóstica como terapéutica, hace que también sean globalmente más frecuentes las complicaciones endoscópicas, siendo la perforación una de las más graves. Sin embargo, también disponemos cada vez de mayores posibilidades a la hora de la resolución endoscópica de las complicaciones iatrogénicas causadas. Presentamos el caso de una perforación de sigma durante una colonoscopia que se resolvió de forma satisfactoria, evitando la cirugía, mediante cierre endoscópico con un clip de nitinol Ovesco®.

Palabras clave: Perforación iatrogénica. Colonoscopia. Ovesco®. Clip de nitinol.


 

Case report

An 82-year-old woman was admitted for assessment of iron deficiency after an episode of syncope. She had a surgical history of hiatal hernia repair 20 years earlier (which subsequently relapsed) and hysterectomy. Tumour markers were normal. Gastroscopy confirmed the presence of a hiatal hernia. Colonoscopy under deep sedation with propofol only and CO2 insufflation revealed no abnormalities in the explored colonic segment. After traversing about 25 cm of the fixed sigmoid colon with difficulty, an iatrogenic perforation occurred. The perforation was immediately noticed and the endoscope was withdrawn, revealing an approximately 12 mm hole 18 cm distal to the anal margin, through which omentum could be seen (Fig. 1).

 

 

Given the clinical stability of the patient, we decided to attempt the endoscopic closure of the perforation with the placement of an Ovesco® clip (Fig. 2). This involved removal of the colonoscope from the colon followed by insertion in the distal end of a therapeutic gastroscope (Olympus GIF 1TQ160), on the end of which was fitted an open nitinol clip mounted on a plastic cap. In this case, an 11-mm clip with rounded edges was selected. After reaching the perforation with the gastroscope, we moved the tip of the endoscope towards it by aspiration. There was no need to pull on the tissue with a clamp. We managed to insert the edges of the perforation into the cap, as well as a fragment of omentum that was aspirated from the colonic lumen. We then deployed the clip, which, when released from the gastroscope cap, closed onto the edges of the perforation, apposing and trapping them. The clip also encircled the aspirated omentum fragment, thus reinforcing closure with an omental patch. Closure was then completed with minimal, superficial residual recess by placement of two endoscopic clips (Boston Scientific®). Finally, the area was explored carefully with a 4.9 mm gastroscope (Olympus GIF N 180), to confirm sealing of the perforation and access to nearby sections (Fig. 3).

 

 

The patient was transferred to the surgical ward for supervision. The surgeon on call had prior knowledge of the case and agreed with use of the endoscopic approach. Vital signs were normal and the patient complained of mild abdominal pain, but there were no signs of developing peritonitis. A liquid diet, fluid replacement, analgesics and broad-spectrum antibiotics were prescribed. At 24 hours, an abdominal CT scan was performed, which showed (Fig. 4) metallic artefacts in the sigmoid colon (consistent with the clips used to seal the perforation) and perihepatic and upper abdominal gas bubbles. A second CT scan performed five days later showed a small fluid collection (2.5 x 2 cm) adjacent to the sigmoid, with no pneumoperitoneum. This collection later disappeared and treatment was continued as originally prescribed. Oral feeding was resumed at 48 hours, and the patient was discharged 10 days after the perforation. At 7-month follow-up, she remains asymptomatic and the metal clip is still in situ, as confirmed by abdominal CT. There were no complications. The patient declined further examination, as she was asymptomatic and her iron deficiency did not worsen.

 

Discussion

Perforation of the colon during colonoscopy may be due to pressure against the bowel wall, barotrauma, or after a range of treatments (1). According to the literature, this complication occurs in 0.01% (2) to 0.3% (3) of colonoscopies, although the rate is less than 0.1% (4) in most series. However, due to the overall increase in the number of colonoscopies performed worldwide and the broader age range of individuals who undergo this procedure, the number of iatrogenic perforations can be substantial.

This is a severe complication and often requires surgery, although isolated case reports and small series of gastrointestinal perforations treated successfully with endoscopy alone have been published in recent years.

To date, the major drawbacks of endoscopic management of iatrogenic perforations have been the inability of clips hitherto, the most widely used system for endoscopic closure, to achieve sufficient apposition of the mucosa or submucosa to ensure sealing of the perforation in most cases (5) and the difficulty of using other suture devices developed for NOTES, some of which have shown efficacy comparable to manual surgical suture (6) but are quite complicated to use.

The Ovesco® system, used in the case described herein, is a novel nitinol clip which is preassembled in the open position on a plastic cap, which can be fitted to the distal end of an endoscope. When released, by means of a spool-and-wire system similar to that used in endoscopic band ligation for oesophageal varices, it closes and traps the edges of the perforation or even the entire thickness of the bowel wall (5). In an animal model, the system demonstrated efficacy similar to that of handmade sutures for closure of gastrointestinal perforations (6). The system is user-friendly, but its applicability may be limited by the fact that insufflation is reduced by the perforation, as the location of the perforation sometimes makes it difficult to approach with the endoscope. Another drawback is that the endoscope must be removed for placement of the device, since it is mounted on the distal end of the endoscope, as are ligature bands.

Perforations of up to 20 mm can be repaired with this clip. In some cases, two Ovesco® clips may be required, or the clip may be used in conjunction with other endoscopic techniques (7). An overall analysis of published studies in humans shows successful closure of the perforation with the Ovesco® system in 91% of patients in whom it was used (8).

Insertion of the edges of the perforation into the plastic cap is often accomplished with a special instrument, consisting of paddles that can be moved independently, or with a three-pronged hook. In our case, however, aspiration was sufficient. We were also able to insert an epiploic appendix into the cap, which was encircled between the edges of the colonic wall to form a safety patch covering the intraperitoneal side of the perforation, ensuring its closure and mimicking a surgical practice (the omental patch) often used when manually suturing such perforations. This method has also been used to seal gastrostomy holes in NOTES (9) procedures, but is not normally part of the endoscopic closure of an iatrogenic perforation.

In our opinion, the fact that insufflation during colonoscopy is performed with CO2 instead of room air was a determining factor in our ability to address this complication in a confident manner, as it helped maintain the hemodynamic stability of the patient throughout the procedure. Furthermore, the absence of signs of peritoneal irritation in the hours following the procedure, removing all doubt as to the proper sealing of the perforation, which could have precluded further conservative management (10), probably played an important role as well.

In our case, the patient remains asymptomatic -and the clip in situ- 7 months after placement, but we are continuing outpatient monitoring due to the limited long-term follow-up experience in patients in whom the Ovesco® system was used for repair of bowel perforation.

Ultimately, the Ovesco® system appears to be a useful tool that should be available to all endoscopy units, as, after appropriate training, it can be used for conservative management of select iatrogenic perforations occurring during digestive endoscopy and thus avoid surgery.

 

References

1. ASGE guideline. Complications of colonoscopy. Gastrointest Endosc 2011;74:745-2.         [ Links ]

2. Sieg A, Hachmoelle-Esisenbach U, Eisenbach T. Prospective evaluation of complications in outpatients GI endoscopy: a survey among German gastroenterologists. Gastrointest Endosc 2011;53:620-7.         [ Links ]

3. Korman LY, Overholt BF, Box T perforation during colonoscopy in endoscopic ambulatory surgical centers. Gastrointest Endosc 2003; 58:554-7.         [ Links ]

4. Ko CW, Dominitz JA. Complications of colonoscopy: magnitude and management. Gastrointest Endosc Clin N Am 2010;20:659-71.         [ Links ]

5. Von Renteln D, Vassiliou MC, Rothstein RI. Randomized controlled trial comparing endoscopic clips and over-the-scope clips for closure of natural orifice transluminal endoscopic surgery gastrostomies. Endoscopy 2009;41:1056-61.         [ Links ]

6. Voermans RP, Vergouwe F, Breedveld P, Fockens P, van berge Henegouwen MI. Comparison of endoscopic closure modalities for standardized colonic perforations in a porcine colon model. Endoscopy 2011;43:217-22.         [ Links ]

7. Parodi A, Repici A, Pedroni A, Blanchi S, Conio M. Endoscopic management of GI perforations with a new over-the-scope clip device. Gastrointest Endosc 2010;72:881-6.         [ Links ]

8. Junquera F, Martínez-Baur E, Miquel M, Fort M, Gallach M, Brullat E, et al. Ovesco: un sistema prometedor de cierre endoscópica de las perforaciones del tracto digestive. Gastroenterol Hepatol 2011; 34:568-72.         [ Links ]

9. Dray X, Giday AS, Buscaglia JM, Gabrielson KL, Kantsevoy SV, Magno P, et al. Omentoplasty for gastrostomy closure after natural orifice transluminal endoscopic surgery procedures. Gastrointest Endosc 2009;70:131-40.         [ Links ]

10. Seebach L, Bauerfeind P, Gubler C. "Sparing the surgeon": Clinical experience with over-the-scope clips for gastrointestinal perforation. Endoscopy 2010;42:1108-11.         [ Links ]

 

 

Correspondence:
Pilar Díez Redondo.
Department of Gastroenterology.
Unit of Endoscopy.
Hospital Universitario Río Hortega.
C/ Dulzaina, 2.
47012 Valladolid, Spain
e-mail: diezmp@hotmail.com

Received: 17-01-2012
Accepted: 11-09-2012

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