Shashideep Singhal, MD, and colleagues from the Brooklyn Hospital Center in Brooklyn, New York present this video case titled “Endoscopic closure of gastric perforation using Over-the-Scope Clip: a surgery-sparing approach.”
A 61-year-old woman with history of diabetes mellitus, sarcoidosis, and chronic oral steroid therapy presented for EGD for evaluation of dysphagia. The patient was found to have 4 arteriovenous malformations in the duodenum, which were cauterized using a gold probe. On withdrawing the endoscope, a linear 2-cm perforation was identified on the lesser curvature 5 cm below the gastroesophageal junction. An over-the-scope clip (OTSC) 12/6 (type gc) was applied endoscopically using a suction technique to close the defect. The patient was asymptomatic on recovery from sedation. A post endoscopy CT scan demonstrated a large amount of free intraperitoneal air and an OTSC on the lesser curvature of stomach. There was no leakage of gastrograffin into the peritoneum. The patient was admitted for observation and discharged home after 48 hours.
The video depicts a gastric perforation during endoscopy. Timely identification of perforation is critical in further management of the complication. We further describe the technique of loading and deployment of an OTSC for endoscopic closure of perforation, which will guide endoscopists in using the device.
Figure 1. A, Endoscopic view during retroflexion showing no perforation. B, Endoscopic view showing linear perforation on the lesser curvature of stomach. C, Endoscopic view showing successful deployment of the OTSC to close perforation completely. D, CT scan showing a large amount of free air in the abdomen and OTSC placement (arrow) at the site of perforation with no leakage of contrast.
Comorbidities and/or advancing age can potentially increase the risk of perforation for low risk procedures. Endoscopists should be watchful to timely identify procedure-related adverse events and consider endoscopic interventions to manage complications when appropriate. OTSCs are an easy to deploy and effective tool for endoscopic closure of small gastric perforations.
OTSCs can be useful in closure of selected esophageal, gastric, duodenal and colonic perforations. Widespread availability and training of endoscopists in endoscopic closure techniques is likely to decrease the morbidity and mortality related with adverse events secondary to iatrogenic perforations.
Watch the video here.
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