An expert report from the American Gastroenterological Association on the update of clinical practice provides advice on treating endoscopic perforations in the gastrointestinal tract, including esophageal, gastric, duodenal, and periampullary perforation, and colon perforation.
There are several techniques for dealing with perforations, including through-the-scope clips (TTSCs), over-the-scope clips (OTSCs), metal self-expanding stents (SEMS), and endoscopic suturing. Newer methods include biological glue and vacuum therapy of the esophagus. These techniques have been the subject of various retrospective analyzes, but few prospective studies have examined their safety and efficacy.
In the expert review published in Clinical Gastroenterology and Hepatology, authors, led by Jeffrey H. Lee, MD, MPH, AGAF, of the Department of Gastroenterology at the MD Anderson Cancer Center, University of Texas, Houston, emphasized that gastroenterologists are one Perforation should have protocol and practice procedures that are used to correct perforation. Endoscopists should also recognize their own limitations and know when a patient should be sent to experienced, high volume centers for further care.
In the event of a perforation, the entire team should be notified immediately and carbon dioxide insufflation performed at a low flow setting. The endoscopist should clean the luminal material to reduce the risk of peritoneal contamination and then treat it with an antibiotic regimen that counteracts Gram-negative and anaerobic bacteria.
Esophageal perforation
Esophageal perforations most commonly occur during stricture dilation, endoscopic mucosal resection (EMR), and endoscopic submucosal dissection (ESD). Perforations of the mucosal flap can occur with so-called third-space endoscopy techniques such as peroral endoscopic myotomy (POEM). Small perforations can easily be treated with TTSCs. Larger perforations require a combination of TTSCs, endoscopic suturing, fibrin glue injection, or esophageal stenting, although the latter is discouraged due to the potential for erosion.
A more worrisome complication of POEM is delayed barrier failure, which can lead to leakage, mediastinitis, or peritonitis. It has been estimated that these complications occur in 0.2% to 1.1% of cases.
In the event of an esophageal perforation, the area should be kept clean by suctioning or changing the patient’s position if necessary. Perforations of 1-2 cm in size can be closed with OTSCs. Excessive bleeding or larger cracks can be treated with a fully covered SEMS.
Leaks that occur in the days following surgery should be closed with TTSCs, OTSCs, or endosuturing, followed by a fully covered stent. Esophageal fistulas should be treated with a fully covered, tight fit stent.
Endoscopic vacuum therapy is a newer technique for treating large or persistent esophageal perforations. One review found that it had a 96% success rate for esophageal perforations.
Gastric perforations
Gastric perforations often result from gastric ulcer disease or the ingestion of corrosive substances and represent a high risk in EMR and ESD procedures (0.4% to 0.7% intraprocedural risk). The proximal stomach wall is not thick as in the gastric antrum, so proximal endoscopic resections require special care. Lengthy procedures should be performed under anesthesia. Persistent gas insufflation during a perforation can exacerbate the problem due to the increased intraperitoneal pressure. OTSCs may be a better choice than TTSCs for 1-3 cm perforations, while Endoloop / TTSC can be used for larger perforations.
Duodenal and periampullary perforations
Duodenal and periampullary perforations occur during duodenal stricture dilatation, EMR, endoscopic submucosal dissection, endoscopic ultrasound, and endoscopic retrograde cholangiopancreatography (ECRP). The thin wall of the duodenum makes it more prone to perforation than the esophagus, stomach, or colon.
Closing a perforation of the duodenum can be difficult. Type 1 perforations typically show sudden bleeding and lumen deflation and often require surgical intervention. Some recent reports have suggested success with TTSCs, OTSCs, tape ligation, and endoloops. Type 2 perforations are less noticeable and the endoscopist has to examine the gas image under the liver or in the area of the right kidney more fluoroscopically. Retroperitoneal air after ERCP, if asymptomatic, does not necessarily require intervention.
The challenges of the duodenum mean that EMR for large duodenal polyps should only be performed by experienced endoscopists with experience in mucosal occlusion, and only experts should attempt ESD. Proteolytic enzymes from the pancreas can also build up in the duodenum, which can break down muscle tissue and lead to delayed perforation. TTSC, OTSC, endosuturing, polymer gels or films and TTSC in combination with endoloop cinching have been used to close resection-associated perforations.
Colon perforation
Colon perforation can be caused by diverticulitis, inflammatory bowel disease, or, occasionally, colon obstruction. Iatrogenic causes are more common and include endoscopic resection, hot forceps biopsy, dilation of strictures due to radiation or Crohn’s disease, colon stenting, and advancing the colonoscope over angulations or into diverticula without straightening the endoscope
Large perforations are usually immediately apparent and should be treated surgically, as are hemodynamic instability or delayed perforations with peritoneal signs.
Endoscopic closure should be attempted when the perforation site is clean, and lower rectal perforations can generally be repaired with TTSC, OTSC, or endoscopic suturing. In the appendix or in a tortured or unclean colon, removing the colonoscope and inserting an OTSC can be difficult or dangerous, and endoscopic suturing may not be possible, making TTSC the only available procedure for right colon perforation. The X-Tack Endoscopic HeliX Tacking System is a recently introduced technology that passes through the endoscope and places sutured staples into the tissue surrounding the perforation and holds it together. The system can in principle close large or irregular large and small intestine perforations with gastroscopes and colonoscopes, but no human studies have been published.
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This update was a joint effort by four endoscopists who believed it was time to review the perforations issue as they can be serious and difficult to manage. However, the development of endoscopic techniques in recent years has resulted in the closure of spontaneous and iatrogenic perforations causing much less anxiety, and they wanted to pool approaches for a wide variety of such situations to guide clinicians who might encounter them.
“While perforation is a serious event, with novel endoscopic techniques and tools the endoscopist should no longer be paralyzed when it occurs,” the authors concluded.
Some authors reported relationships such as B. Advice or royalties from device companies such as Medtronic and Boston Scientific. The other authors did not report any conflicts.
This article originally appeared on MDedge.com, part of the Medscape Professional Network.
