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Reprint requests: Sergey V. Kantsevoy, MD, PhD, Institute for Digestive Health and Liver Diseases at Mercy Medical Center, 301 St. Paul Place, POB 7th Floor, Suite 718, Baltimore, MD 21202.
Affiliations
Institute for Digestive Health and Liver Diseases, Mercy Medical Center, Baltimore, Maryland, USAUniversity of Maryland School of Medicine, Baltimore, Maryland, USA
Perforation during colonoscopy remains the most worrisome adverse event and usually requires urgent surgical rescue. The aim of this study was to evaluate the feasibility and effectiveness of endoscopic closure of full-thickness colonic perforations.
Methods
We performed a retrospective analysis of all consecutive patients with endoscopically closed colonic perforations over the past 6 years (2009-2014). Colonic perforations were closed by using endoscopic clips or an endoscopic suturing device. Most patients were admitted for treatment with intravenous antibiotics and kept on bowel rest. If their clinical condition deteriorated, urgent surgery was performed. If patients remained stable, oral feeding was resumed, and patients were discharged with subsequent clinical and endoscopic follow-up.
Results
Twenty-one patients had iatrogenic colonic perforations closed with an endoscopic suturing device or endoscopic clips during the study period. Primary closure of a colonic perforation was performed with endoscopic clips in 5 patients and sutured with an endoscopic suturing device in 16 patients. All 5 patients after clip closure had worsening of abdominal pain and required laparoscopy (4 patients) or rescue colonoscopy with endoscopic suturing closure (1 patient). Two patients had abdominal pain after endoscopic suturing closure, but diagnostic laparoscopy confirmed complete and adequate endoscopic closure of the perforations. The other 15 patients did not require any rescue surgery or laparoscopy after endoscopic suturing. The main limitation of our study is its retrospective, single-center design and relatively small number of patients.
Conclusion
Endoscopic suturing closure of colonic perforations is technically feasible, eliminates the need for rescue surgery, and appears more effective than closure with hemostatic endoscopic clips.
Perforation of the colonic wall remains the most worrisome adverse event of endoscopic intervention, and usually requires immediate open or laparoscopic surgical repair or colon resection.
Considering the reported perforation rate of 0.1% (1:1000) during screening colonoscopy, at least 14,200 colonic perforations are estimated to occur in the United States every year.
Therapeutic interventions, such as removal of colonic polyps or resection of early colon cancer, have an even higher perforation rate compared with screening colonoscopy. The latest published meta-analysis reported a perforation rate of 1.4% during 973 colonic EMRs and a 5.7% rate of perforation during 1326 colonic endoscopic submucosal dissections (ESDs).
Efficacy and adverse events of EMR and endoscopic submucosal dissection for the treatment of colon neoplasms: a meta-analysis of studies comparing EMR and endoscopic submucosal dissection.
Previous studies have demonstrated successful endoscopic closure of colonic perforations with both endoscopic clips and suturing devices on live animal models.
However, in our review of available medical literature, we were unable to find any large study devoted to endoscopic closure of colonic perforations in humans other than several reports involving a small number of patients.
The target sign: an endoscopic marker for the resection of the muscularis propria and potential perforation during colonic endoscopic mucosal resection.
We performed a retrospective analysis of colonic perforations treated endoscopically at our institution over the past 6 years to evaluate the feasibility and effectiveness of endoscopic closure of full-thickness perforations encountered during colonoscopy.
Methods
We obtained permission from the institutional review board of Mercy Medical Center to perform a retrospective analysis of medical records of consecutive adult patients who had endoscopic closure of documented colonic perforations over the past 6 years (2009-2014).
All patients had undergone screening or therapeutic colonoscopy. Demographic and clinical data including patient age, sex, indications for colonoscopy, pathological diagnosis, lesion size and location, adverse events, and follow-up results were collected for all patients. All data were entered into an Excel database and analyzed. Our primary study outcome was to determine the need for rescue laparoscopic or open surgery after endoscopic repair of a colonic perforation.
All endoscopic repairs of colonic perforations were performed by the same endoscopist (S.V.K.) with the patient under intravenous sedation or general anesthesia. All procedures were performed with carbon dioxide insufflation.
When the perforation was diagnosed during colonoscopy, we continued the same mode of anesthesia, the patient was given intravenous antibiotics, and an attempt to repair the perforation was made with either endoscopic clips (Resolution; Boston Scientific Inc, Natick, Mass) or an endoscopic suturing device (Overstitch; Apollo Endosurgery Inc, Austin, Tex). Endoscopic clips were applied through the biopsy channel of the colonoscope used for the primary procedure (PCF-H180AL or CF-H180AL; Olympus, Tokyo, Japan).
To perform endoscopic suturing closure of a colonic perforation, the colonoscope was removed, and a double-channel endoscope (GiF 2T-180; Olympus) preloaded with an Overstitch endoscopic suturing device was inserted. The colonic wall defect was completely closed by full-thickness sutures creating a continuous suture line or by separated stitches, as described previously.
To release pneumoperitoneum, a sterile angiocatheter (BD Insyte Autoguard Infusion Therapy System; Boston Dickinson Inc, Sandy, Utah) or Veress needle (Endopath Ethicon Endo-Surgery, LLC, Guaynabo, Puerto Rico) connected to a syringe with a sterile normal saline solution was placed in the peritoneal cavity through the abdominal wall (Video 1, available online at www.giejournal.org). After completion of the suturing closure to confirm airtight closure, an air-leak test was performed (Video 2, available online at www.giejournal.org), and then the angiocatheter (or Veress needle) was removed.
After colonoscopy, initial blood work (complete blood cell count, coagulation, and metabolic profile) was performed, and an abdominal radiograph in the flat and upright position (to determine the presence of intraperitoneal air) was taken. Most patients were admitted for observation and kept on bowel rest with intravenous fluids and antibiotics. If the clinical condition deteriorated (increased intensity of abdominal pain or clinical signs of peritonitis), urgent laparoscopy was performed by the collaborating surgeon. If the patient remained stable for 24 hours, oral feeding was resumed, and the patient was discharged home. Subsequent clinical follow-up included a phone conversation within 7 to 14 days to discuss biopsy results and any problems or adverse events. Repeat endoscopic evaluation was performed in 3 months. If the suture material was still present during the follow-up endoscopy, it was cut with endoscopic scissors (Loop Cutter FS-5U-1; Olympus) and removed.
Results
From 2009 to 2014, colonic perforations were closed endoscopically in 21 patients (Table 1). In 12 patients, colonoscopies were performed with the patient under deep sedation, whereas in 9, the patients were under general anesthesia.
Table 1Characteristics of the study patients
Patient
Age, y
Sex, M/F
BMI, kg/m2
Lesion size, mm
Lesion location
Procedure
Closure technique
1
78
F
25.1
40
Cecum
EMR
Clips
2
71
F
22.3
40
Ascending
EMR
Clips
3
65
F
30.8
40
Cecum
EMR
Clips
4
61
F
26.5
15
Cecum
EMR
Clips
5
55
F
22.0
10
Cecum
EMR
Clips/suture
6
44
F
29.9
10
Sigmoid
EMR
Suture
7
59
F
24.8
N/A
Sigmoid
Screening
Suture
8
56
F
21.6
60
Sigmoid
ESD
Suture
9
70
F
43.9
30
Sigmoid
ESD
Suture
10
60
F
37.7
30
Transverse
ESD
Suture
11
30
M
26.3
50
Sigmoid
ESD
Suture
12
51
M
37.6
30
Ascending
ESD
Suture
13
69
F
26.6
20
Ascending
ESD
Suture
14
72
F
31.1
60
Ascending
ESD
Suture
15
51
F
28.5
50
Transverse
ESD
Suture
16
51
M
27.8
20
Transverse
ESD
Suture
17
81
F
24.4
50
Ascending
ESD
Suture
18
50
M
23.0
30
Transverse
ESD
Suture
19
65
F
33.3
N/A
Transverse
Dilation
Suture
20
58
F
33.2
N/A
Sigmoid
Screening
Suture
21
65
F
19.3
30
Descending
EMR
Suture
M/F, Male/female; BMI, body mass index; N/A, not available; ESD, endoscopic submucosal dissection.
Primary closure of colonic perforations was performed with endoscopic clips in 5 patients (Fig. 1) and with an Overstitch endoscopic suturing device in 16 patients (Fig. 2).
Figure 1Colonic perforation closure with endoscopic clips. A, Large, sessile cecal polyp. B, Full-thickness colonic perforation after polyp removal. C, Perforation closed with endoscopic clips.
Patients in both groups (clip closure and endoscopic suturing closure) were similar in age (66.0 ± 8.9 vs 58.3 ± 12.4, P = .212) and body mass index (25.3 ± 3.6 vs 29.3 ± 6.6, P = .217). Perforation occurred during screening colonoscopy in 2 patients (patients 7 and 20) and during dilation of a colonic stricture in 1 patient (patient 19). Perforation during EMR was encountered in 7 patients, and perforation during ESD occurred in 11 patients (Fig. 3; Video 3, available online at www.giejournal.org).
Figure 3Closure of a colonic perforation during ESD with an endoscopic suturing device. A, Large, sessile polyp in the descending colon. B, A full-thickness perforation during ESD. C, ESD is completed. D, Double-channel endoscope preloaded with an endoscopic suturing device is advanced toward the ESD site to start suturing. E, Colonic perforation and large mucosal defect after ESD completely closed with 1 continuous suturing line. ESD, endoscopic submucosal dissection.
Visually obvious colonic perforations ranged in size from 3 to 15 mm (mean size, 6.6 ± 3.9 mm). In 5 patients, colonic perforations (mean size, 3.4 ± 2.1 mm; range 3-5 mm) encountered during EMR were closed with endoscopic clips (mean number of clips per patient, 5.6 ± 3.0; range 2-9) and required on average 17.5 ± 9.3 minutes per patient for endoscopic closure of the perforation. All 5 patients who underwent endoscopic clip closure of documented colonic perforations had increased abdominal pain after the procedure. In 4 patients, urgent laparoscopy was performed and confirmed inadequate closure of the perforation. Laparoscopic colon resection with an ileocolonic anastomosis was performed in each patient. There were no intraoperative or postoperative adverse effects.
After clip closure of the cecal perforation, patient 5 experienced severe abdominal pain on awakening after the procedure. An immediate rescue colonoscopy for perforation closure was performed with the patient under intravenous sedation. A double-channel upper endoscope preloaded with an Overstitch endoscopic suturing device was inserted in the cecum. The 3 previously placed endoscopic clips were removed with a snare, and then the postpolypectomy mucosal defect and perforation were completely closed with 2 continuous sutures. The patient reported complete pain relief after endoscopic suturing, required no additional intervention other than antibiotics, and was discharged home in stable condition.
In the other 16 patients, full-thickness colonic perforations (mean size, 5.6 ± 4.8 mm) were closed with an endoscopic suturing device. Advancement of the relatively short double-channel upper endoscope loaded with an endoscopic suturing device into the right side of the colon sometimes required application of abdominal pressure and a change in the patient’s position. Suturing with the Overstitch endoscopic suturing device was technically easy and fast (the mean suturing time was 13.4 ± 9.1 minutes per patient). It required only 1 stitch (continuous suturing line) for complete closure in 9 patients, 2 stitches in 4 patients, and 3 stitches in 3 patients (a mean of 1.6 ± 0.8 stitches per patient). The actual perforation was closed full-thickness by driving the needle through the entire colonic wall under endoscopic guidance creating airtight closure documented by a carbon dioxide leak test (Video 2). The remaining post-EMR or post-ESD defect was completely closed with sutures through mucosal and submucosal layers.
After endoscopic suturing closure, 2 patients reported continuous abdominal pain. Diagnostic laparoscopy was performed on both patients and confirmed complete and adequate suturing closure of the perforation with no apparent inflammatory changes, peritoneal contamination, or infected fluid inside the peritoneal cavity (Video 4, available online at www.giejournal.org).
The other 14 patients with endoscopic suturing closure did not require rescue surgery or laparoscopy and were discharged home in stable condition with no symptoms. Follow-up colonoscopy in 3 months demonstrated complete healing of the previous perforation and EMR/ESD site in all patients (Fig. 4; Video 5, available online at www.giejournal.org). Scarring from the defect closure was minimal, and no residual polypoid tissue remained. Endoscopic sutures were retained by 7 patients, which were easily cut with endoscopic scissors and removed.
Figure 4Follow-up colonoscopy in 3 months demonstrating complete healing of previous perforation and post-ESD defect in the patient in Figure 3. A, Previous perforation and mucosal defect after ESD healed completely. Previously made endoscopic suture is still attached. B, The suture is cut off with endoscopic scissors. C, The suture is removed. There is no residual polypoid tissue. A small granuloma near the site of previous ESD will be removed with endoscopic forceps and sent for histological evaluation. ESD, endoscopic submucosal dissection.
Wider implementation of screening colonoscopy, improved polyp detection, and introduction of more aggressive endoscopic procedures for removal of colonic polyps (EMR and ESD) could cause an increased number of colonic perforations.
Efficacy and adverse events of EMR and endoscopic submucosal dissection for the treatment of colon neoplasms: a meta-analysis of studies comparing EMR and endoscopic submucosal dissection.
Although previous animal experiments demonstrated the technical feasibility of colonic perforation closure with endoscopic clips and sutures, so far no dedicated clinical study has compared the reliability of various endoscopic techniques for closure of colonic perforations in humans.
The Overstitch endoscopic suturing device was introduced to clinical practice by Apollo Endosurgery Inc (Austin, Tex) in 2011. Previous studies have reported successful use of this device for closure of gastrocutaneous fistulae and anastomotic ulcers, fixation of internal stents, assistance during ESD, repair of upper GI tract perforations, and closure of large mucosal defects after ESD.
Facilitating endoscopic submucosal dissection: the suture-pulley method significantly improves procedure time and minimizes technical difficulty compared with conventional technique: an ex vivo study (with video).
Endoscopic suturing closure of large mucosal defects after endoscopic submucosal dissection is technically feasible, fast, and eliminates the need for hospitalization (with videos).
We analyzed the use of endoscopic clips and the endoscopic suturing device for treatment of documented colonic perforations. Although several previous case reports demonstrated successful closure of colonic perforations with endoscopic clips,
The target sign: an endoscopic marker for the resection of the muscularis propria and potential perforation during colonic endoscopic mucosal resection.
our data indicate that for larger perforations (mean perforation size in our clip closure group was 3.4 ± 2.1 mm), through-the-scope endoscopic clips designed for hemostatic purpose cannot adequately close full-thickness perforation. Despite the visually adequate closure of colonic perforations with endoscopic clips in 5 of our study patients, all of these patients (100%) clinically deteriorated after clip closure and required additional rescue procedures. In the first 4 patients (patients 1-4), laparoscopic exploration confirmed inadequate mucosal closure with endoscopic clips and necessitated resection of the affected colonic segment. In patient 5, colonoscopy was repeated, clips were removed, and endoscopic suturing was performed as a rescue technique. Successful closure of the colonic perforation was achieved. The patient experienced immediate relief of abdominal pain, eliminating the need for surgical exploration.
We previously demonstrated the clinical effectiveness of the Overstitch endoscopic suturing device for suturing closure of large partial-thickness (mucosal-submucosal) defects after ESD.
Endoscopic suturing closure of large mucosal defects after endoscopic submucosal dissection is technically feasible, fast, and eliminates the need for hospitalization (with videos).
The endoscopic suturing device deploys robust sutures that allow reliable tissue approximation of the mucosal and submucosal layers, complete closure of even large tissue defects, and prevention of delayed adverse events (eg, perforation, bleeding) after ESD.
Endoscopic suturing closure of large mucosal defects after endoscopic submucosal dissection is technically feasible, fast, and eliminates the need for hospitalization (with videos).
Contrary to only mucosal approximation with endoscopic clips, endoscopic suturing closure of a colonic perforation creates a full-thickness “surgical” quality suture through all layers of the colonic wall, creating an airtight closure, documented by a carbon dioxide leak test. Diagnostic laparoscopy in 2 of our study patients confirmed complete and adequate endoscopic suturing closure of the colonic perforation. None of the patients who received endoscopic suturing closure of a colonic perforation required any colon resection or additional intraperitoneal laparoscopic sutures.
Although we were able to suture even perforations located in the ascending colon and cecum in 5 patients (29.4%), delivery of the Overstitch endoscopic suturing device into the right side of the colon can be difficult due to a relatively short length of a double-channel upper endoscope used with the current (second-generation) endoscopic suturing device. To correct this problem, Apollo Endosurgery is currently finalizing development of the third generation of the Overstitch device, which will be mounted on single-channel upper endoscopes and single-channel adult and/or pediatric colonoscopes.
Use of an endoscopic suturing device for closure of perforations during colonoscopy has very obvious clinical and economic benefits. Clinically, it eliminates skin incisions and the risk of postoperative hernias, prevents resection of the affected colonic segment, and provides the patient a much quicker recovery than surgical intervention can offer. The use of the Overstitch endoscopic suturing device ($599) and the cost of 1 suture with a cinch ($138) added only $875 per patient requiring an average of 1.6 ± 0.8 sutures. This is significantly less expensive than laparoscopic or open surgical abdominal exploration with colonic resection or repair ($8404-$10,496)
Large refractory colonic polyps: is it time to change our practice? A prospective study of the clinical and economic impact of a tertiary referral colonic mucosal resection and polypectomy service (with videos).
and results in an average cost savings of approximately $7529 to $9621 per patient. In reality, the cost saving per patient is even greater considering the longer in-hospital admission after laparoscopic or surgical intervention compared with 24-hour observation after colonoscopy with endoscopic suturing of a colonic perforation.
The main limitation of our study is its retrospective, single-center design and relatively small number of patients. Larger prospective, multicenter studies will be needed to confirm these preliminary results.
In conclusion, endoscopic suturing closure of colonic perforations is technically feasible, eliminates the need for rescue surgery, and appears more effective than closure with hemostatic endoscopic clips.
Leak test confirms airtight suturing closure of a colonic perforation: insufflation of carbon dioxide into the colonic lumen through the endoscope does not cause any air bubbles inside the syringe.
Closure of a colonic perforation during ESD with endoscopic suturing device. A large, sessile polyp in the descending colon. Submucosal injection of normal saline solution with indigo carmine is performed to lift the polyp. A circumferential incision around the polyp is started with a dual knife causing a large full-thickness perforation. ESD is continued until the lesion is removed en bloc. Then the colonic perforation and large mucosal defect after ESD is completely closed with 1 continuous suturing line. A submucosal injection of India ink is performed to mark the location. ESD, endoscopic submucosal dissection.
Laparoscopic view demonstrating complete and adequate suturing closure of a colonic perforation with no apparent inflammatory changes, peritoneal contamination, or infected fluid inside the peritoneal cavity.
Follow-up colonoscopy in 3 months after endoscopic suturing closure of a perforation encountered during ESD (demonstrated in Figure 3 and Video 3). The previous perforation and mucosal defect after ESD healed completely. The previously made endoscopic suture is still attached. The suture is cut off with endoscopic scissors and removed. There is no residual polypoid tissue. A small granuloma near the site of the previous ESD was removed with endoscopic forceps and sent for histological evaluation. ESD, endoscopic submucosal dissection.
Efficacy and adverse events of EMR and endoscopic submucosal dissection for the treatment of colon neoplasms: a meta-analysis of studies comparing EMR and endoscopic submucosal dissection.
The target sign: an endoscopic marker for the resection of the muscularis propria and potential perforation during colonic endoscopic mucosal resection.
Facilitating endoscopic submucosal dissection: the suture-pulley method significantly improves procedure time and minimizes technical difficulty compared with conventional technique: an ex vivo study (with video).
Endoscopic suturing closure of large mucosal defects after endoscopic submucosal dissection is technically feasible, fast, and eliminates the need for hospitalization (with videos).
Large refractory colonic polyps: is it time to change our practice? A prospective study of the clinical and economic impact of a tertiary referral colonic mucosal resection and polypectomy service (with videos).
DISCLOSURE: Dr Kantsevoy is a cofounder of and shareholder in Apollo Endosurgery Inc. All other authors disclosed no financial relationships relevant to this publication.
This author read with great interest the article by Kantsevoy et al1 on endoscopic management of colonic perforations: closure by clips versus suturing. In this retrospective study, primary closure of a colonic perforation was performed with endoscopic through-the-scope (TTS) clips in 5 patients and sutured with an endoscopic suturing device in 16 patients. All 5 patients after EMR with cecal perforation (mean size, 3.4 ± 2.1 mm; range 3-5 mm) after clip closure had worsening of abdominal pain and required laparoscopy (4 patients) or rescue colonoscopy with endoscopic suturing closure (1 patient).
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