FEASIBILITY AND EFFICACY OF DOUBLE OVER-THE-SCOPE CLIPPING FOR COLONIC IATROGENIC PERFORATION

Colo-rectal iatrogenic perforation is a rare complication in diagnostic colonoscopy, occurring in a range of 0.03%-0.8%. Risk factors comprehend endoscopist inexperience, female gender, peri-colic adhesions, inflammatory colonic diseases, diverticular disease, greater age due to weakened colonic wall tissues. Over-the-scope clipping device (OTSC, Ovesco Endoscopy GmbH, Tübingen, Germany) is a useful tool, recommended as first-line endoscopic treatment for endoscopic iatrogenic perforation, which can avoid emergency surgical repair. The deployment of over-the-scope clipping device may be in some cases challenging, due to the size, the position of the hole, the presence of other endoscopic devices to completely close the defect. To the best of our knowledge, there's not described the deployment of two adjacent over-the-scope clipping devices.

Here we report the video-case of an 89-year-old woman referred to our unit to perform colonoscopy (CFHQ190L; Olympus Co., Japan), because of positive hemoccult test and anemia. Because of peri-colic adhesions in a picture of severe diverticular disease, a perforation of about 20 – 25 mm occurred in the sigmoid-rectal junction. After positioning of naso-gastric tube and Verres needle to favour abdominal decompression, a preliminary deployment of over-the-scope clipping device (11/6 mm traumatic type) with suction technique didn't achieve the complete seal of the defect. Another analogous over-the-scope clipping device was deployed with suction technique tightly adjacent to the first one. It was gained the complete closure of the leakage, as confirmed by injection of contrast medium and subsequent computed tomography scan. The latter also excluded malignant colonic disease. The suction technique was applied, without using of the twin grasper or of the anchor, because of softness of the edges, in the context of acute perforation. All the procedure was performed with anesthesiological assistance, using CO₂ insufflation. No further complication occurred, broad spectrum antibiotics were administered and the patient was discharged asymptomatic 1 week later. In conclusion, even challenging, the closely deployment of two over-the-scope clipping devices can be feasible and effective to treat iatrogenic perforations, in experienced hands. In this high anesthesiological risk patient, it avoided later complications or surgical repair.