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
