Endoscopic closure of large colonic perforations using an over-the-scope clip: a randomized controlled porcine study

D. von Renteln; A. Schmidt; M. C. Vassiliou; H.-U. Rudolph; M. Gieselmann; K. Caca

doi:10.1055/s-0029-1214759

Endoscopy, Inhaltsverzeichnis

Endoscopy 2009; 41(6): 481-486
DOI: 10.1055/s-0029-1214759

Original article

Endoscopic closure of large colonic perforations using an over-the-scope clip: a randomized controlled porcine study

D. von Renteln¹ , A. Schmidt¹ , M. C. Vassiliou² , H.-U. Rudolph³ , M. Gieselmann³ , K. Caca¹

¹Department of Gastroenterology, Medizinische Klinik I, Klinikum Ludwigsburg, Ludwigsburg, Germany
²Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
³University Hospital Mannheim, University of Heidelberg, Germany

Abstract

Background and study aims: Perforation of the colon is considered to be one of the most serious complications of flexible endoscopy. The over-the-scope clip system (OTSC) has previously been shown to close small colonic perforations effectively. The aim of this randomized controlled porcine study was to compare acute closure strengths between the novel 11-mm over-the-scope-clip and surgical closure for large colonic perforations.

Material and methods: In 24 anesthetized domestic pigs, an 18-mm sigmoid perforation was created endoscopically using a needle knife and dilating balloon. The animals were randomly assigned to undergo either open surgical repair (n = 12) or endoscopic closure using the OTSC system (n = 12). Pressurized leak tests were performed during necropsy.

Results: Mean time to perform the incision in the sigmoid colon and obtain peritoneal access was 5.5 minutes (range 3 – 12; SD ± 2.5). Mean time for endoscopic closure was 6.8 minutes (range 3 – 14; SD ± 3). At necropsy, all OTSC and surgical closures demonstrated complete sealing of colotomy sites. In one case peritoneum and in a second case adjacent small intestine were found incorporated into the OTSC closure. No other complications occurred. Pressurized leak tests revealed a mean burst pressure of 62.8 mmHg (range 18 – 112; SD 35.7) for OTSC closures and 67.4 mmHg (range 30 – 90; SD 19) for sutured closure. No significant differences in burst pressures were noted between the OTSC closures and surgical repair.

Conclusion: Closure of acute perforations using the OTSC system is comparable to surgical closure in a nonsurvival porcine model.

Volltext

Referenzen

References

1 Magdeburg R, Collet P, Post S. et al . Endoclipping of iatrogenic colonic perforation to avoid surgery. Surg Endosc. 2008; 22 1500-1504
2 Christie J P, Marrazzo 3rd J. ”Mini-perforation” of the colon – not all postpolypectomy perforations require laparotomy. Dis Colon Rectum. 1991; 34 132-135
3 Dafnis G, Ekbom A, Pahlman L, Blomqvist P. Complications of diagnostic and therapeutic colonoscopy within a defined population in Sweden. Gastrointest Endosc. 2001; 54 302-309
4 Damore 2nd L J, Rantis P C, Vernava 3rd A M, Longo W E. Colonoscopic perforations. Etiology, diagnosis, and management. Dis Colon Rectum. 1996; 39 1308-1314
5 Freitag M, Albert W, Petersen S, Ludwig K. Iatrogenic colon perforation from the viewpoint of the surgeon. Experiences with 11 patients. Chirurg. 2000; 71 568-571
6 Cobb W S, Heniford B T, Sigmon L B. et al . Colonoscopic perforations: incidence, management, and outcomes. Am Surg. 2004; 70 750-757
7 Lo A Y, Beaton H L. Selective management of colonoscopic perforations. J Am Coll Surg. 1994; 179 333-337
8 Nelson R L, Abcarian H, Prasad M L. Iatrogenic perforation of the colon and rectum. Dis Colon Rectum. 1982; 25 305-308
9 Fruhmorgen P, Demling L. Complications of diagnostic and therapeutic colonoscopy in the Federal Republic of Germany. Results of an inquiry. Endoscopy. 1979; 11 146-150
10 Iqbal C W, Chun Y S, Farley D R. Colonoscopic perforations: a retrospective review. J Gastrointest Surg. 2005; 9 229-1235
11 Devereaux C E, Binmoeller K F. Endoclip: closing the surgical gap. Gastrointest Endosc. 1999; 50 440-442
12 Raju G S, Ahmed I, Shibukawa G. et al . Endoluminal clip closure of a circular full-thickness colon resection in a porcine model. Gastrointest Endosc. 2007; 65 503-509
13 Raju G S, Ahmed I, Xiao S Y. et al . Controlled trial of immediate endoluminal closure of colon perforations in a porcine model by use of a novel clip device. Gastrointest Endosc. 2006; 64 989-997
14 Schurr M O, Hartmann C, Kirschniak A. et al . Experimental study on a new method for colonoscopic closure of large bowel perforations with the OTSC clip. Biomed Tech. 2008; 53 45-51
15 Schurr M O, Hartmann C, Ho C N. et al . An over-the-scope clip (OTSC) system for closure of iatrogenic colon perforations: results of an experimental survival study in pigs. Endoscopy. 2008; 40 584-588
16 Pham B V, Raju G S, Ahmed I. et al . Immediate endoscopic closure of colon perforation by using a prototype endoscopic suturing device: feasibility and outcome in a porcine model. Gastrointest Endosc. 2006; 64 113-119
17 Raju G S, Pham B, Xiao S Y. et al . A pilot study of endoscopic closure of colonic perforations with endoclips in a swine model. Gastrointest Endosc. 2005; 62 791-795
18 Albuquerque W, Moreira E, Arantes V. et al . Endoscopic repair of a large colonoscopic perforation with clips. Surg Endosc. 2008; 22 2072-2074
19 Pham B V, Morgan K, Romagnuolo J. et al . Pilot comparison of adhesion formation following colonic perforation and repair in a pig model using a transgastric, laparoscopic, or open surgical technique. Endoscopy. 2008; 40 664-669
20 Raju G S, Fritscher-Ravens A, Rothstein R I. et al . Endoscopic closure of colon perforation compared to surgery in a porcine model: a randomized controlled trial. Gastrointest Endosc. 2008; 68 324-332
21 Ryou M, Fong D G, Pai R D. et al . Dual-port distal pancreatectomy using a prototype endoscope and endoscopic stapler: a natural orifice transluminal endoscopic surgery (NOTES) survival study in a porcine model. Endoscopy. 2007; 39 881-887
22 Yoshikane H, Hidano H, Sakakibara A. et al . Endoscopic repair by clipping of iatrogenic colonic perforation. Gastrointest Endosc. 1997; 46 464-466
23 Ryou M, Fong D G, Pai R D. et al . Evaluation of a novel access and closure device for NOTES applications: a transcolonic survival study in the porcine model. Gastrointest Endosc. 2008; 67 964-969
24 Mana F, De Vogelaere K, Urban D. Iatrogenic perforation of the colon during diagnostic colonoscopy: endoscopic treatment with clips. Gastrointest Endosc. 2001; 54 258-259
25 Trecca A, Gaj F, Gagliardi G. et al . Our experience with endoscopic repair of large colonoscopic perforations and review of the literature. Tech Coloproctol. 2008; 12 315-322
26 Trecca A, Gaj F. Large iatrogenic colonic perforation repaired endoscopically with Triclip. Tech Coloproctol. 2007; 11 87
27 Luning T H, Keemers-Gels M E, Barendregt W B. et al . Colonoscopic perforations: a review of 30 366 patients. Surg Endosc. 2007; 21 994-997
28 Barbagallo F, Castello G, Latteri S. et al . Successful endoscopic repair of an unusual colonic perforation following polypectomy using an endoclip device. World J Gastroenterol. 2007; 13 2889-2891
29 Schlinkert R T. Laparoscopic treatment of colonoscopic perforations. Mayo Clin Proc. 1998; 73 98
30 Agresta F, Michelet I, Mainente P, Bedin N. Laparoscopic management of colonoscopic perforations. Surg Endosc. 1998; 14 592-593
31 Velez M A, Riff D S, Mule J M. Laparoscopic repair of a colonoscopic perforation. Surg Endosc. 1997; 11 387-389
32 Pilgrim C H, Nottle P D. Laparoscopic repair of iatrogenic colonic perforation. Surg Laparosc Endosc Percutan Tech. 2007; 17 215-217
33 Wullstein C, Koppen M, Gross E. Laparoscopic treatment of colonic perforations related to colonoscopy. Surg Endosc. 1999; 13 484-487
34 Rogers J, Misiewicz J J. Fully automated computer analysis of intracolonic pressures. Gut. 1989; 30 642-649
35 Rogers J, Henry M M, Misiewicz J J. Increased segmental activity and intraluminal pressures in the sigmoid colon of patients with the irritable bowel syndrome. Gut. 1989; 30 634-641
36 Loeing-Bauche V, Anuras S. Effects of a meal on the motility of the sigmoid colon and rectum in healthy adults. Am J Gastroenterol. 1983; 78 393-397
37 Narducci F, Bassotti G, Gaburri M, Morelli A. Twenty four hour manometric recording of colonic motor activity in healthy man. Gut. 1987; 28 17-25
38 Trotman I F, Misiewicz J J. Sigmoid motility in diverticular disease and the irritable bowel syndrome. Gut. 1988; 29 218-222
39 Ryou M, Fong D G, Pai R D. et al . Transluminal closure for NOTES: an ex vivo study comparing leak pressures of various gastrotomy and colotomy closure modalities. Endoscopy. 2008; 40 432-436
40 Voermans R P, Worm A M, van Berge Henegouwen M I. et al . In vitro comparison and evaluation of seven gastric closure modalities for natural orifice transluminal endoscopic surgery (NOTES). Endoscopy. 2008; 40 595-601
41 Renteln D von, Eickhoff A, Kaehler G. et al . Endoscopic closure of the natural orifice transluminal endoscopic surgery (NOTES) access site to the peritoneal cavity by means of transmural resorbable sutures: an animal survival study. Endoscopy. 2009; 41 146-149
42 McGee M F, Marks J M, Jin J. et al . Complete endoscopic closure of gastric defects using a full-thickness tissue plicating device. J Gastrointest Surg. 2008; 12 38-45
43 McGee M F, Marks J M, Onders R P. et al . Complete endoscopic closure of gastrotomy after natural orifice translumenal endoscopic surgery using the NDO Plicator. Surg Endosc. 2008; 22 214-220

K. CacaMD

Department of Gastroenterology, Hepatology and Oncology
Klinikum Ludwigsburg

71640 Ludwigsburg
Germany

Fax: +49-7141-9967219

eMail: renteln@gmx.net