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DOI: 10.1055/s-0031-1291642
Endoscopic band ligation to create an omental patch for closure of a colonic perforation
Corresponding author
Publication History
Publication Date:
06 March 2012 (online)
A 56-year-old woman underwent colonoscopy for colorectal cancer surveillance. At a difficult rectosigmoid turn, a 1.5-cm perforation developed, but application of two endoscopic clips (HX-610-090 L, Olympus, Tokyo, Japan) failed to close the perforation because of the awkward angle ([Fig. 1]). A banding device (MBL-6, Wilson-Cook, Winston-Salem, North Carolina, USA) loaded on a gastroscope was then used to suck the nearby omentum to complete closure of the perforation, aided by one of the clips serving as a landmark to pinpoint the location of the perforation ([Fig. 2]). Subsequently, a computed tomography (CT) scan of the whole abdomen with rectal contrast revealed pneumoperitoneum, pneumoretroperitoneum, pneumomediastinum, and right pneumothorax, and confirmed absence of contrast leakage ([Fig. 3]). The patient was admitted and the pneumothorax was successfully treated with conservative measures, that is, the patient had no oral intake for 1 week and was given broad-spectrum antibiotics. After another 2 days, she was able to tolerate a step-up diet and was discharged. At the 1-month follow-up she had no complaints and reported normal bowel movement.
The rectosigmoid colon is vulnerable to perforation because of its angulation [1] [2]. Perforation at the rectosigmoid junction can lead to pneumoperitoneum as well as pneumoretroperitoneum because the junction is located within both the retroperitoneal and the intraperitoneal spaces. A pneumothorax may occur when air dissects through the mediastinal pleura into the pleural space [3]. The success rate of clipping for closure of a colonic perforation is about 42 % – 82 % [4] [5]. For successful endoscopic clipping the perforation should be less than 10 mm in size, as larger sizes carry a significant risk of unfavorable outcome [5], and there needs to be enough space available for passing the scope under direct visualization [4] [5]. In our patient clipping was unsuccessful as the perforation was more than 1 cm in size and located at the angulated part of the rectosigmoid colon. Fortunately, we were able to use one of the previously deployed clips as a guide and suck the nearby omentum to create an omental patch endoscopically.
Endoscopy_UCTN_Code_TTT_1AQ_2AG
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Competing interests: None
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References
- 1 Khashab MA, Pickhardt PJ, Kim DH et al. Colorectal anatomy in adults at computed tomography colonography: normal distribution and the effect of age, sex, and body mass index. Endoscopy 2009; 41: 674-678
- 2 Hanson ME, Pickhardt PJ, Kim DH et al. Anatomic factors predictive of incomplete colonoscopy based on findings at CT colonography. AJR Am J Roentgenol 2007; 189: 774-779
- 3 Maunder RJ, Pierson DJ, Hudson LD. Subcutaneous and mediastinal emphysema. Pathophysiology, diagnosis, and management. Arch Intern Med 1984; 144: 1447-1453
- 4 Jovanovic I, Zimmermann L, Fry LC et al. Feasibility of endoscopic closure of an iatrogenic colon perforation occurring during colonoscopy. Gastrointest Endosc 2011; 73: 550-555
- 5 Cho SB, Lee WS, Joo YE et al. Therapeutic options for iatrogenic colon perforation: feasibility of endoscopic clip closure and predictors of the need for early surgery. Surg Endosc 23. 09. 2011 [Epub ahead of print]
Corresponding author
-
References
- 1 Khashab MA, Pickhardt PJ, Kim DH et al. Colorectal anatomy in adults at computed tomography colonography: normal distribution and the effect of age, sex, and body mass index. Endoscopy 2009; 41: 674-678
- 2 Hanson ME, Pickhardt PJ, Kim DH et al. Anatomic factors predictive of incomplete colonoscopy based on findings at CT colonography. AJR Am J Roentgenol 2007; 189: 774-779
- 3 Maunder RJ, Pierson DJ, Hudson LD. Subcutaneous and mediastinal emphysema. Pathophysiology, diagnosis, and management. Arch Intern Med 1984; 144: 1447-1453
- 4 Jovanovic I, Zimmermann L, Fry LC et al. Feasibility of endoscopic closure of an iatrogenic colon perforation occurring during colonoscopy. Gastrointest Endosc 2011; 73: 550-555
- 5 Cho SB, Lee WS, Joo YE et al. Therapeutic options for iatrogenic colon perforation: feasibility of endoscopic clip closure and predictors of the need for early surgery. Surg Endosc 23. 09. 2011 [Epub ahead of print]