Reply to Katsinelos et al.

We greatly appreciate the thoughtful comments by Katsinelos et al. The immediate endoscopic management of colonic perforations has emerged as an alternative efficacious and safe procedure in the appropriate clinical setting for prevention of abdominal contamination and subsequent surgical morbidity, mortality, and prolonged hospitalization [1]. The use of endoscopic clipping is the first and most widely used technique for treating iatrogenic colonic perforations for reasons of availability, simplicity, performance, and safety.

The recognition of a perforation during colonoscopy necessitates an immediate action in order to avoid leakage of bacterial load into the peritoneal cavity and resultant septic complications. This goal can be compromised by inadequate air insufflation due to air leakage from the perforated site, the limited maneuverability of the endoscope in the narrow bowel lumen, or flexures, brisk hemorrhage, incomplete bowel cleansing, as well as size and shape of the perforation. The endoscopic clips have been repeatedly used with success for treating perforations up to 10 mm in size. The commercially available endoluminal clips offer a maximum opening width of 12 mm and a maximum clip length after deployment of 15.5 mm, with variable rotatability and re-opening capabilities [2]. These options, along with the increasing familiarity of the endoscopist in the handling of such devices and the gradually established conviction of their efficacy, have recently led to case reports on the successful use of clips for larger perforations up to 35 mm [3] [4] [5]. Under experimental conditions in live porcine models, the clips showed a success rate of 75 % for sealing linear perforations 50 mm in size and preventing peritoneal contamination [6].

The problem still exists for the potential closure of large circular perforations above the peritoneal reflexion. The purse-string technique with the combined use of endoloop and clips has been presented by Katsinelos et al. as an alternative endoscopic technique for sealing sizeable perforations. One of the first reports on the application of this technique by Matsuda et al. refers to the treatment of a 50-mm defect after endoscopic mucosal resection of a laterally spreading tumor lesion in the lower rectum; three endoloops were used as a preventive measure to avoid delayed bleeding from the resection bed and not to seal a true perforation [7]. The closure of a large diagnostic perforation in the duodenal bulb, caused by the tip of an echoendoscope, in a purse-string fashion has also been presented in another report [8]. In this case, the echoendoscope was exchanged for a single-channel gastroscope and the endoloop was placed over the base of the clips after their application at the periphery of the lesion in order to encircle and tighten the clips together to approximate the mucosal edges. Even with this variation in the technique, the net closure time has been reported to be 10 minutes with favorable outcome given the absence of retained gastric and duodenal contents. The perforation treated effectively by Katsinelos et al. was reported as a 30-mm defect at the margin of the peritoneal reflexion in the lower rectum caused by retroflexion of the endoscope [9].

Based on the aforementioned cases it becomes evident that the original purse-string technique can be very useful, even though it exhibits a narrow therapeutic window. An important prerequisite is the use of a double-channel endoscope. The manipulation of the endoloop under emergency conditions requires more advanced endoscopic expertise than the application of clips. The maximum opening diameter of a detachable snare is 30 mm [10], which still limits the size of the treatable lesions. The procedure requires a considerable amount of time to take effect in a clinical setting in which immediate action is an important determinant of prevention of peritoneal irritation. Prolonged procedures can cause deterioration of the pneumoperitoneum due to air insufflation to maintain a clear view, which might ultimately impose, if severe enough, respiratory and cardiovascular compromise (the so-called abdominal compartment syndrome). The limited number of reports is derived from tertiary medical centers with highly experienced endoscopists working on selective cases, and it will be exciting to see more experience develop with this new technique.

In conclusion, the endoloop/clips technique represents a novel and promising endoscopic method of treating larger colonic perforations even though the technique has its own limitations with, until now, little international experience.

Competing interests: None

References

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