Endoscopy 2009; 41(6): 481-486
DOI: 10.1055/s-0029-1214759
Original article

© Georg Thieme Verlag KG Stuttgart · New York

Endoscopic closure of large colonic perforations using an over-the-scope clip: a randomized controlled porcine study

D. von  Renteln1 , A.  Schmidt1 , M.  C.  Vassiliou2 , H.-U.  Rudolph3 , M.  Gieselmann3 , K.  Caca1
  • 1Department of Gastroenterology, Medizinische Klinik I, Klinikum Ludwigsburg, Ludwigsburg, Germany
  • 2Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
  • 3University Hospital Mannheim, University of Heidelberg, Germany
Further Information

Publication History

submitted 28 January 2009

accepted after revision 24 April 2009

Publication Date:
16 June 2009 (online)

Background and study aims: Perforation of the colon is considered to be one of the most serious complications of flexible endoscopy. The over-the-scope clip system (OTSC) has previously been shown to close small colonic perforations effectively. The aim of this randomized controlled porcine study was to compare acute closure strengths between the novel 11-mm over-the-scope-clip and surgical closure for large colonic perforations.

Material and methods: In 24 anesthetized domestic pigs, an 18-mm sigmoid perforation was created endoscopically using a needle knife and dilating balloon. The animals were randomly assigned to undergo either open surgical repair (n = 12) or endoscopic closure using the OTSC system (n = 12). Pressurized leak tests were performed during necropsy.

Results: Mean time to perform the incision in the sigmoid colon and obtain peritoneal access was 5.5 minutes (range 3 – 12; SD ± 2.5). Mean time for endoscopic closure was 6.8 minutes (range 3 – 14; SD ± 3). At necropsy, all OTSC and surgical closures demonstrated complete sealing of colotomy sites. In one case peritoneum and in a second case adjacent small intestine were found incorporated into the OTSC closure. No other complications occurred. Pressurized leak tests revealed a mean burst pressure of 62.8 mmHg (range 18 – 112; SD 35.7) for OTSC closures and 67.4 mmHg (range 30 – 90; SD 19) for sutured closure. No significant differences in burst pressures were noted between the OTSC closures and surgical repair.

Conclusion: Closure of acute perforations using the OTSC system is comparable to surgical closure in a nonsurvival porcine model.

References

  • 1 Magdeburg R, Collet P, Post S. et al . Endoclipping of iatrogenic colonic perforation to avoid surgery.  Surg Endosc. 2008;  22 1500-1504
  • 2 Christie J P, Marrazzo 3rd J. ”Mini-perforation” of the colon – not all postpolypectomy perforations require laparotomy.  Dis Colon Rectum. 1991;  34 132-135
  • 3 Dafnis G, Ekbom A, Pahlman L, Blomqvist P. Complications of diagnostic and therapeutic colonoscopy within a defined population in Sweden.  Gastrointest Endosc. 2001;  54 302-309
  • 4 Damore 2nd L J, Rantis P C, Vernava 3rd A M, Longo W E. Colonoscopic perforations. Etiology, diagnosis, and management.  Dis Colon Rectum. 1996;  39 1308-1314
  • 5 Freitag M, Albert W, Petersen S, Ludwig K. Iatrogenic colon perforation from the viewpoint of the surgeon. Experiences with 11 patients.  Chirurg. 2000;  71 568-571
  • 6 Cobb W S, Heniford B T, Sigmon L B. et al . Colonoscopic perforations: incidence, management, and outcomes.  Am Surg. 2004;  70 750-757
  • 7 Lo A Y, Beaton H L. Selective management of colonoscopic perforations.  J Am Coll Surg. 1994;  179 333-337
  • 8 Nelson R L, Abcarian H, Prasad M L. Iatrogenic perforation of the colon and rectum.  Dis Colon Rectum. 1982;  25 305-308
  • 9 Fruhmorgen P, Demling L. Complications of diagnostic and therapeutic colonoscopy in the Federal Republic of Germany. Results of an inquiry.  Endoscopy. 1979;  11 146-150
  • 10 Iqbal C W, Chun Y S, Farley D R. Colonoscopic perforations: a retrospective review.  J Gastrointest Surg. 2005;  9 229-1235
  • 11 Devereaux C E, Binmoeller K F. Endoclip: closing the surgical gap.  Gastrointest Endosc. 1999;  50 440-442
  • 12 Raju G S, Ahmed I, Shibukawa G. et al . Endoluminal clip closure of a circular full-thickness colon resection in a porcine model.  Gastrointest Endosc. 2007;  65 503-509
  • 13 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.  Gastrointest Endosc. 2006;  64 989-997
  • 14 Schurr M O, Hartmann C, Kirschniak A. et al . Experimental study on a new method for colonoscopic closure of large bowel perforations with the OTSC clip.  Biomed Tech. 2008;  53 45-51
  • 15 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
  • 16 Pham B V, Raju G S, Ahmed I. et al . Immediate endoscopic closure of colon perforation by using a prototype endoscopic suturing device: feasibility and outcome in a porcine model.  Gastrointest Endosc. 2006;  64 113-119
  • 17 Raju G S, Pham B, Xiao S Y. et al . A pilot study of endoscopic closure of colonic perforations with endoclips in a swine model.  Gastrointest Endosc. 2005;  62 791-795
  • 18 Albuquerque W, Moreira E, Arantes V. et al . Endoscopic repair of a large colonoscopic perforation with clips.  Surg Endosc. 2008;  22 2072-2074
  • 19 Pham B V, Morgan K, Romagnuolo J. et al . Pilot comparison of adhesion formation following colonic perforation and repair in a pig model using a transgastric, laparoscopic, or open surgical technique.  Endoscopy. 2008;  40 664-669
  • 20 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.  Gastrointest Endosc. 2008;  68 324-332
  • 21 Ryou M, Fong D G, Pai R D. et al . Dual-port distal pancreatectomy using a prototype endoscope and endoscopic stapler: a natural orifice transluminal endoscopic surgery (NOTES) survival study in a porcine model.  Endoscopy. 2007;  39 881-887
  • 22 Yoshikane H, Hidano H, Sakakibara A. et al . Endoscopic repair by clipping of iatrogenic colonic perforation.  Gastrointest Endosc. 1997;  46 464-466
  • 23 Ryou M, Fong D G, Pai R D. et al . Evaluation of a novel access and closure device for NOTES applications: a transcolonic survival study in the porcine model.  Gastrointest Endosc. 2008;  67 964-969
  • 24 Mana F, De Vogelaere K, Urban D. Iatrogenic perforation of the colon during diagnostic colonoscopy: endoscopic treatment with clips.  Gastrointest Endosc. 2001;  54 258-259
  • 25 Trecca A, Gaj F, Gagliardi G. et al . Our experience with endoscopic repair of large colonoscopic perforations and review of the literature.  Tech Coloproctol. 2008;  12 315-322
  • 26 Trecca A, Gaj F. Large iatrogenic colonic perforation repaired endoscopically with Triclip.  Tech Coloproctol. 2007;  11 87
  • 27 Luning T H, Keemers-Gels M E, Barendregt W B. et al . Colonoscopic perforations: a review of 30 366 patients.  Surg Endosc. 2007;  21 994-997
  • 28 Barbagallo F, Castello G, Latteri S. et al . Successful endoscopic repair of an unusual colonic perforation following polypectomy using an endoclip device.  World J Gastroenterol. 2007;  13 2889-2891
  • 29 Schlinkert R T. Laparoscopic treatment of colonoscopic perforations.  Mayo Clin Proc. 1998;  73 98
  • 30 Agresta F, Michelet I, Mainente P, Bedin N. Laparoscopic management of colonoscopic perforations.  Surg Endosc. 1998;  14 592-593
  • 31 Velez M A, Riff D S, Mule J M. Laparoscopic repair of a colonoscopic perforation.  Surg Endosc. 1997;  11 387-389
  • 32 Pilgrim C H, Nottle P D. Laparoscopic repair of iatrogenic colonic perforation.  Surg Laparosc Endosc Percutan Tech. 2007;  17 215-217
  • 33 Wullstein C, Koppen M, Gross E. Laparoscopic treatment of colonic perforations related to colonoscopy.  Surg Endosc. 1999;  13 484-487
  • 34 Rogers J, Misiewicz J J. Fully automated computer analysis of intracolonic pressures.  Gut. 1989;  30 642-649
  • 35 Rogers J, Henry M M, Misiewicz J J. Increased segmental activity and intraluminal pressures in the sigmoid colon of patients with the irritable bowel syndrome.  Gut. 1989;  30 634-641
  • 36 Loeing-Bauche V, Anuras S. Effects of a meal on the motility of the sigmoid colon and rectum in healthy adults.  Am J Gastroenterol. 1983;  78 393-397
  • 37 Narducci F, Bassotti G, Gaburri M, Morelli A. Twenty four hour manometric recording of colonic motor activity in healthy man.  Gut. 1987;  28 17-25
  • 38 Trotman I F, Misiewicz J J. Sigmoid motility in diverticular disease and the irritable bowel syndrome.  Gut. 1988;  29 218-222
  • 39 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
  • 40 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
  • 41 Renteln D von, Eickhoff A, Kaehler G. et al . Endoscopic closure of the natural orifice transluminal endoscopic surgery (NOTES) access site to the peritoneal cavity by means of transmural resorbable sutures: an animal survival study.  Endoscopy. 2009;  41 146-149
  • 42 McGee M F, Marks J M, Jin J. et al . Complete endoscopic closure of gastric defects using a full-thickness tissue plicating device.  J Gastrointest Surg. 2008;  12 38-45
  • 43 McGee M F, Marks J M, Onders R P. et al . Complete endoscopic closure of gastrotomy after natural orifice translumenal endoscopic surgery using the NDO Plicator.  Surg Endosc. 2008;  22 214-220

K. CacaMD 

Department of Gastroenterology, Hepatology and Oncology
Klinikum Ludwigsburg

71640 Ludwigsburg
Germany

Fax: +49-7141-9967219

Email: renteln@gmx.net

    >