ABSTRACT
Iatrogenic gastrointestinal perforation is one of the severe adverse events of endoscopic therapeutic procedure. For acute iatrogenic perforation,management by endoscopic techniques is a simple and rapid modality to close the perforation with minimal invasiveness and avoiding the traditional surgical trauma. Endoclips,suture with special instruments,covered stents,degradable sheets combined with tissue adhesive,and combined endoscopic techniques such as snares combined with endoclips,are the major endoscopic therapeutic modalities for closure of iatrogenic gastrointestinal perforation. In this article,the current status and progress of endoscopic management for acute iatrogenic gastrointestinal perforation were reviewed.
ABSTRACT
A 73-year-old woman was admitted to evaluate for iron deficiency anemia, increased serum creatinine, and ascites. Her colonoscopy revealed a polyp at the junction of sigmoid and descending colon, and after polypectomy, a 6 mm colonic perforation was seen. The perforation was detected by radiography and CT scan; and beside conservative management and antibiotics, her perforation was closed by using Endoclip. The patient was observed and discharged from hospital without any surgery 5 days later, and in follow-up there was no problem regarding perforation. (AU)
Mulher, 73 anos, internada para avaliação para anemia ferropriva, com aumento da creatinina sérica e ascite. A colonoscopia revelou um pólipo na junção dos colos sigmoide e descendente e, em seguida à polipectomia, foi observada uma perfuração de 6 mm no cólon, comprovada por radiografias e tomografia computadorizada. Além do tratamento conservador e da antibioticoterapia, a perfuração foi ocluída com Endoclip. A paciente ficou sob observação e recebeu alta do hospital sem qualquer cirurgia 5 dias mais tarde. Durante o seguimento, não foram observados problemas com relação à perfuração. (AU)
Subject(s)
Humans , Female , Aged , Surgical Instruments/adverse effects , Colonic Polyps/surgery , Intestinal Perforation/etiology , Colon/injuriesABSTRACT
Objective To design a novel endoscopic successive hemostasis and closing device, and to validate whether the device can meet the needs of tissue closure by finite element analysis. Methods By using the novel device, the target tissue was clamped and the clip was then pushed to pierce the tissue. Under the compression between the clip and the inner side of the grasper, the thinner arms of the clip were forced to bend and close to stay in the tissue, and then the inverse displacement of 2 mm was applied on the clip. The elastic limit and tensile strength of the clip were set as 239.0 and 901.0 MPa, respectively. Results Deformation did not occur in the piercing process of the clip, with the maximum stress of 212.6 MPa. The deformed shape of the clip in the bending process matched its design expectation, with the maximum stress of 727.7 MPa. The maximum stress of the clip was 75.8 MPa under 2-mm inverse displacement. Material failure was not found in the bending process or with 2-mm inverse displacement, and the maximum stress in the whole process was 741.0 MPa. Conclusions The novel endoscopic successive hemostasis and closing device proposed in this study can deploy 4 clips at one time, together with an independent grasper for gathering tissues, which can shorten the reloading time and improve the accuracy of clip deployment. The effectiveness and safety of the device is also proved by using finite element method.
ABSTRACT
Iatrogenic perforation during endoscopy is associated to significant morbidity and mortality, and presents a high incidence due to the increasing number of endoscopic procedures and the frequency of complex therapeutic procedures. Evidence available to decide which is the best strategy to manage patients with iatroenic perforation is scarce, mainly due to rare occurrence of this complication. The European Society of Gastroenterology (ESGE) published their Position Statement on Diagnosis and management of iatrogenic endoscopic perforations including recommendations for developing a strategy for the prevention and management of iatrogenic perforations in the gastrointestinal tract. Among the multiple recommendations, the following have shown a reduction in the morbi-mortality rate: implementing a written protocol on the management of these complications; including information on their location, and initial endoscopic management; carrying out a CT if signs or symptoms are present; attempting endoscopic closure, depending on the type of perforation, its size and endoscopic expertise; change to CO2 insufflation; derivation of luminal contents and decompression of pneumoperitoneum or pneumothorax; and finally, considering additional management based on successful closure of the perforation and on the patients clinical condition, as well as early surgical resolution if no endoscopic closure is performed or if the procedure fails in patients with poor clinical condition.
La perforación iatrogénica durante los procedimientos endoscópicos se asocia a significativa morbilidad y mortalidad y presenta una incidencia creciente por el alto número exploraciones endoscópicas y la realización cada vez más frecuente de procedimientos terapéuticos complejos. La evidencia disponible para decidir cuál es la mejor estrategia para manejar a los pacientes con una perforación iatrogénica es escasa, principalmente debido a lo inhabitual de esta complicación. La Sociedad Europea de Endoscopia Gastrointestinal (ESGE) publicó su Declaración de Posición de Diagnóstico y Manejo de Perforaciones Endoscópicas Iatrogénicas en la que formula diversas recomendaciones para desarrollar una estrategia de prevención y manejo de perforaciones iatrogénicas del tubo digestivo. Dentro de las principales recomendaciones, las siguientes han demostrado una reducción en la morbimortalidad: implementar un protocolo escrito sobre el manejo de estas complicaciones; incluir en el informe datos sobre su tamaño, localización y manejo endoscópico inicial; la realización de una tomografía computada ante síntomas o signos sugerentes; intentar el cierre endoscópico, dependiendo del tipo de perforación, su tamaño y la experiencia endoscópica disponible; el cambio a insuflación con CO2; la derivación del contenido luminal y la descompresión del neumoperitoneo o neumotórax a tensión; y finalmente, basar el manejo adicional en el éxito estimado del cierre y en la condición clínica del paciente, considerando la resolución quirúrgica precoz en caso de no realizar un cierre endoscópico o falla de éste y/o en pacientes con deterioro clínico.
Subject(s)
Humans , Endoscopy, Digestive System/adverse effects , Intestinal Perforation/etiology , Colonoscopy/adverse effects , Guidelines as TopicABSTRACT
Objective To evaluate the feasibility and effectiveness of four closure techniques ,large incision with plastic distal at‐tachment and clip with suction ,1 .1 cm small incision with plastic distal attachment and clip with suction in natural orifice translu‐minal endoscopic surgery(NOTES) .Methods Forty‐one ex vivo porcine stomachs were involved in this research .According to the size of incision and different methods of incision closure ,all ex vivo porcine stomachs were divided into four groups .Group A in‐volved 8 ex vivo porcine stomachs ,their size of incision were 1 .2-2 .0 cm ,and their incisions were closured by a clip closure direct‐ly ;group B involved 10 ex vivo porcine stomachs ,their size of incision were 1 .2-2 .0 cm ,and their incisions were closed by plastic end attachment with suction and clip enclosure technique;group C involved 10 ex vivo porcine stomachs ,their size of incision were smaller than 1 .1 cm ,and their incisions were by a clip closure directly ;group D involved 13 ex vivo porcine stomachs ,their size of incision were smaller than 1 .1 cm ,and closured by plastic end attachment with suction and clip enclosure technique .Stomach leaks were evaluated by leaking studies after the procedure .Results In group A ,1 incision was closed successfully ,7 incisions were clo‐sured unsuccessfully ;in group B ,2 incisions were closed successfully ,8 incisions were closed unsuccessfully ;in group C ,2 incisions were closed successfully ,8 incisions were closured unsuccessfully ;in group D ,11 incisions were closed successfully ,2 incisions were Closured unsuccessfully .Fisher′s exact test showed that group D was significantly related to the success of incision closure .The were significant differences between group A and D ,group B and group D(P<0 .05) .Conclusion Small incision(smaller than 1 cm) and plastic end attachment with suction and clip enclosure technique are optimal in NOTES procedure in this ex vivo porcine stomachs study .
ABSTRACT
Brunner's gland adenoma is a rare benign tumor that is usually asymptomatic and it the result of a benign proliferation of the Brunner's glands of the duodenum. In symptomatic patients, the common clinical presentation is gastrointestinal bleeding and obstructive symptoms. A 48-year-old man presented with abdominal discomfort and vomiting. The endoscopic examination revealed a large pedunculated polypoid mass arising in the bulb and it was prolapsing through the pylorus into the antrum, and this all resulted in a ball-valve obstruction. After endoclips were applied at the peduncle of the mass, this polyp was simply and successfully cut with using an IT-knife without bleeding or perforation. We report here on a case of Brunner's gland adenoma that caused a ball-valve obstruction, and the tumor was removed by a simple and easy method with using endoclips and an IT-knife.