Endoscopy 2011; 43(3): 217-222
DOI: 10.1055/s-0030-1256072
Original article

© Georg Thieme Verlag KG Stuttgart · New York

Comparison of endoscopic closure modalities for standardized colonic perforations in a porcine colon model

R.  P.  Voermans1,2 , F.  Vergouwe1,2 , P.  Breedveld3 , P.  Fockens1 , M.  I.  van Berge Henegouwen2
  • 1Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
  • 2Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
  • 3Department of Biomechanical Engineering, University of Technology, Delft, The Netherlands
Further Information

Publication History

submitted 12 March 2010

accepted after revision 18 October 2010

Publication Date:
01 March 2011 (online)

Background and study aim: Colonic perforation is a serious complication of colonoscopy, with surgical repair usually indicated. The aim was to compare acute strength of various endoscopic colonic closure techniques by assessing air leak pressures in a previously described ex vivo experimental apparatus.

Methods: Standardized colonic perforations were created using fresh porcine colon and subsequently closed on a bench. Six techniques included surgical suture (gold standard), QuickClips, T-tags, over-the-scope-clip (OTSC) system, and two types of flexible stapler (Covidien). After closure, each specimen was fixed in the apparatus and pressure was gradually increased until air bubbles were seen. Leak pressure was the primary outcome parameter. Closure using the gold standard (first 15 experiments) resulted in a mean leak pressure of 86.9 mmHg (SD 7). Using a noninferiority design a sample size of 12 specimens for each closure technique was determined.

Results: Mean colotomy leak pressures in millimeters of mercury (mmHg) and difference (with 95 % confidence intervals [CI]) between each technique and the gold standard were: QuickClips 85.1 (difference –1.8; 95 %CI –7.0 to 3.9); T-tags 53.9 (difference –33.0; –39.0 to –27.0); OTSC 90.3 mmHg (difference 3.4; –6.1 to 12.9); 15-mm shaft stapler 98.5 mmHg (difference 9.7; 0.8 to 18.5) and 8-mm shaft stapler 96.6 mmHg (difference 11.6; 1.5 to 21.7).

Conclusions: OTSCs, QuickClips, and both flexible staplers produced results comparable to hand-sewn colotomy closure in this ex vivo porcine colonic model. These devices seem to be prime candidates for further evaluation in survival animal studies.

References

  • 1 Iqbal C W, Cullinane D C, Schiller H J et al. Surgical management and outcomes of 165 colonoscopic perforations from a single institution.  Arch Surg. 2008;  143 701-706
  • 2 Dafnis G, Ekbom A, Pahlman L et al. Complications of diagnostic and therapeutic colonoscopy within a defined population in Sweden.  Gastrointest Endosc. 2001;  54 302-309
  • 3 Regula J, Rupinski M, Kraszewska E et al. Colonoscopy in colorectal-cancer screening for detection of advanced neoplasia.  N Engl J Med. 2006;  355 1863-1872
  • 4 Warren J L, Klabunde C N, Mariotto A B et al. Adverse events after outpatient colonoscopy in the Medicare population.  Ann Intern Med. 2009;  150 849-857, W152
  • 5 Prismant. Utrecht, The Netherlands; www.prismant.nl
  • 6 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 (with videos).  Gastrointest Endosc. 2006;  64 989-997
  • 7 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 (with videos).  Gastrointest Endosc. 2008;  68 324-332
  • 8 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
  • 9 Sporn E, Miedema B W, Bachman S L et al. Endoscopic colotomy closure after full thickness excision: comparison of T fastener with multiclip applier.  Endoscopy. 2008;  40 589-594
  • 10 Renteln D von, Schmidt A, Vassiliou M C et al. Endoscopic closure of large colonic perforations using an over-the-scope clip: a randomized controlled porcine study.  Endoscopy. 2009;  41 481-486
  • 11 Albuquerque W, Moreira E, Arantes V et al. Endoscopic repair of a large colonoscopic perforation with clips.  Surg Endosc. 2008;  22 2072-2074
  • 12 Kirschniak A, Kratt T, Stuker D et al. A new endoscopic over-the-scope clip system for treatment of lesions and bleeding in the GI tract: first clinical experiences.  Gastrointest Endosc. 2007;  66 162-167
  • 13 Repici A, Arezzo A, De C G et al. Clinical experience with a new endoscopic over-the-scope clip system for use in the GI tract.  Dig Liver Dis. 2009;  41 406-410
  • 14 Yoshikane H, Hidano H, Sakakibara A et al. Endoscopic repair by clipping of iatrogenic colonic perforation.  Gastrointest Endosc. 1997;  46 464-466
  • 15 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
  • 16 Voermans R P, van Berge Henegouwen M I, Bemelman W A et al. Novel over-the-scope clip system for gastrotomy closure in natural orifice transluminal endoscopic surgery (NOTES): an ex vivo comparison study.  Endoscopy. 2009;  41 1052-1055
  • 17 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
  • 18 Fang J F, Chen R J, Lin B C. Controlled reopen suture technique for pyloric exclusion.  J Trauma. 1998;  45 593-596
  • 19 Feitoza A B, Gostout C J, Rajan E et al. Understanding endoluminal gastroplications: a histopathologic analysis of intraluminal suture plications.  Gastrointest Endosc. 2003;  57 868-876
  • 20 diZerega G S. Biochemical events in peritoneal tissue repair.  Eur J Surg Suppl. 1997;  577 10-16
  • 21 Fong D G, Pai R D, Thompson C C. Transcolonic endoscopic abdominal exploration: a NOTES survival study in a porcine model.  Gastrointest Endosc. 2007;  65 312-318 . Epub 2006 Dec 14
  • 22 Pai R D, Fong D G, Bundga M E et al. Transcolonic endoscopic cholecystectomy: a NOTES survival study in a porcine model (with video).  Gastrointest Endosc. 2006;  64 428-434
  • 23 Raju G S, Ahmed I, Brining D et al. Endoluminal closure of large perforations of colon with clips in a porcine model (with video).  Gastrointest Endosc. 2006;  64 640-646
  • 24 Raju G S, Shibukawa G, Ahmed I et al. Endoluminal suturing may overcome the limitations of clip closure of a gaping wide colon perforation (with videos).  Gastrointest Endosc. 2007;  65 906-911
  • 25 Voermans R P, van Berge Henegouwen M I, Bemelman W et al. Hybrid NOTES transgastric cholecystectomy with reliable gastric closure; an animal survival study.  Surg Endosc. 2010;  Aug19 [Epub ahead of print]
  • 26 Bachman S L, Sporn E, Furrer J L et al. Colonic sterilization for natural orifice translumenal endoscopic surgery (NOTES) procedures: a comparison of two decontamination protocols.  Surg Endosc. 2009;  23 1854-1859
  • 27 Fong D G, Ryou M, Pai R D et al. Transcolonic ventral wall hernia mesh fixation in a porcine model.  Endoscopy. 2007;  39 865-869
  • 28 Sporn E, Bachman S L, Miedema B W et al. Endoscopic colotomy closure for natural orifice transluminal endoscopic surgery using a T-fastener prototype in comparison to conventional laparoscopic suture closure.  Gastrointest Endosc. 2008;  68 724-730
  • 29 Voermans R P, van Berge Henegouwen M I, Bemelman W A et al. Feasibility of transgastric and transcolonic natural orifice transluminal endoscopic surgery peritoneoscopy combined with intraperitoneal EUS.  Gastrointest Endosc. 2009;  69 e61-e67
  • 30 Cobb W S, Heniford B T, Sigmon L B et al. Colonoscopic perforations: incidence, management, and outcomes.  Am Surg. 2004;  70 750-757
  • 31 Hagen M E, Wagner O J, Christen D et al. Cosmetic issues of abdominal surgery: results of an enquiry into possible grounds for a natural orifice transluminal endoscopic surgery (NOTES) approach.  Endoscopy. 2008;  40 581-583
  • 32 Varadarajulu S, Tamhane A, Drelichman E R. Patient perception of natural orifice transluminal endoscopic surgery as a technique for cholecystectomy.  Gastrointest Endosc. 2008;  67 854-860
  • 33 Bassotti G, de Roberto G, Chistolini F et al. Twenty-four-hour manometric study of colonic propulsive activity in patients with diarrhea due to inflammatory (ulcerative colitis) and non-inflammatory (irritable bowel syndrome) conditions.  Int J Colorectal Dis. 2004;  19 493-497
  • 34 Zambuto D, Bramson R T, Blickman J G. Intracolonic pressure measurements during hydrostatic and air contrast barium enema studies in children.  Radiology. 1995;  196 55-58

M. I. van Berge HenegouwenMD, PhD 

Department of Surgery, G4
Academic Medical Center

Meibergdreef 9
1105 AZ Amsterdam
The Netherlands

Fax: +31-20-5669243

Email: M.I.vanBergeHenegouwen@amc.nl