Post written by Ravishankar Asokkumar, MBBS, MRCP, from the Department of Gastroenterology and Hepatology, Singapore General Hospital, and DUKE-NUS Graduate Medical School, Singapore.
We described a case demonstrating the endoscopic closure technique of a large iatrogenic gastric perforation presenting in a delayed fashion. The perforation was closed using multiple over-the-scope clips, and we avoided surgery.
Traditionally, gastrointestinal perforations are managed mainly by surgery. However, the morbidity associated with surgery can be high. With the availability of several newer endoscopic devices and accessories, endoscopic closure may now be considered as the first-line treatment option to manage perforations. The over-the-scope clipping (OTSC) device was developed to treat gastrointestinal bleeding and perforation. Using the OTSC accessories, we can capture a larger amount of tissue and achieve better tissue approximation when clipping.
The key to successful treatment depends on adherence to the principles of endoscopic closure, which include:
- Evacuation of pneumoperitoneum.
- Assessing the morphology of perforation and cleaning it adequately.
- Refreshing the edges of perforation using APC.
- Achieving complete closure of the defect without any leak.
- Initiating early enteral nutrition and antibiotic therapy.
- Draining collections surrounding the perforation, if any.
- Follow-up imaging to assess the integrity of closure.
The video demonstrates each of these steps and illustrates the technique for placement of multiple over-the-scope clips to achieve double-layered suture closure of the defect similar to surgery.
Endoscopic closure of gastrointestinal defects in an appropriate clinical setting may transform patient outcomes significantly. Being familiar with the endoscopic closure techniques and over-the-scope clip application may enable endoscopists to manage such situations effectively.
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