Early closure of an iatrogenic gastrointestinal defect reduces related adverse events.
The closure method depends on the size and location of the defect [1]
[2]. Delayed closure may complicate treatment.
Our patient was a 68-year-old man with sepsis secondary to iatrogenic perforation
of the lower rectum during a Bricker-type cystectomy for bladder carcinoma T2N0M0.
During surgery, the anterior rectal wall was accidentally perforated and sutured in
the same act. The patient did not recover well after the operation (clinical and lab
evaluations). On the 10th postoperative day, persistent rectal perforation was confirmed
by computed tomography (CT). The patient was reoperated on to suture the rectal lesion,
but without success, and a loop colostomy was performed. A further 7 days later his
clinical condition had worsened, with hemodynamic changes and sepsis. Repeat CT demonstrated
persistence of the perforation and a large air–fluid level at the left lateroconal
fascia, requiring percutaneous drainage. A colonoscopy was performed and showed abundant
fecal remains in the rectal ampulla. A 35-mm orifice was observed at 3 cm from the
anal margin, connecting with the peritoneal cavity with abundant purulent and fecaloid
content. Inside the cavity, a surgical drainage catheter was visualized and was relocated
under endoscopic vision until it drained the collection. As peritoneal communication
contraindicates endoscopic placement of a vacuum system, a fully covered 20 mm × 10
cm stent (Niti-S Enteral Colonic Covered Stent; Taewoong Medical) was inserted with
its distal end outside the anal margin. Ten days later, the stent was removed. The
perforation edges had matured ([Fig. 1]), so we treated them with argon and sutured them using a novel endoscopic suturing
device: 4 through-the-scope tack device kits (X-Tack Endoscopic HeliX Tacking System;
Boston Scientific) ([Video 1]). Complete closure of the perforation was achieved. After this procedure, the patient
had a favorable outcome, without associated rectal tenesmus. After 2 days, he was
discharged.
Fig. 1 Iatrogenic rectal perforation in a 68-year-old man.
Through-the-scope tack and suture system used to repair a large iatrogenic rectal
perforation.Video 1
X-Tack is a simple, useful, and accessible suture method with a low complication rate,
and is a minimally invasive alternative to surgery, enabling the closure of large
iatrogenic gastrointestinal perforations [3].
Endoscopy_UCTN_Code_CPL_1AJ_2AD_3AD
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