Delayed successful treatment of iatrogenic colon perforation using an over-the-scope clip

Over-the-scope clip closure of iatrogenic gastrointestinal tract perforations has been successfully demonstrated, and is usually performed in the immediate peroperative setting [1] [2]. We report the first case, to our knowledge, of delayed successful treatment of an iatrogenic colon perforation using an over-the-scope clip.

An 80-year-old woman underwent routine colonoscopy. Her medical history was unremarkable apart from unexplained thrombocytopenia (40 000 platelets/dL). During endoscopy, a perforation occurred at the level of the sigmoid junction with the left colon ([Fig. 1]). At that time, after multidisciplinary discussion, and in view of the successful colonic preparation and the thrombocytopenia, a mini-invasive endoscopic treatment was proposed (the patient being on antibiotics). Two and a half hours later the patient was transferred to our unit for an attempt at clip closure. Using a gastroscope and CO2 insufflation, a 7-mm perforation orifice was visualized. An OTSC 11/6 t clip (Ovesco Endoscopy GmbH, Tübingen, Germany) was then delivered, with aspiration of the edges of the orifice ([Fig. 2], [Fig. 3]). Contrast medium study through the endoscope performed at that time did not show any fluid extravasation ([Fig. 4]).

Fig. 1 Colon perforation with visualization of the epiploon.

Fig. 2 Perforation orifice and 11/6 t over-the-scope clip.

Fig. 3 Over-the-scope in place.

Fig. 4 Watertight closure with no extravasation of contrast medium.

The day after the procedure, the patient presented localized peritoneal irritation and fever (38 °C). Lab tests showed no hyperleukocytosis, but the C-reactive protein level had increased to 204 U/L. Spiral CT with bowel opacification performed then confirmed a sealed clip closure with no free fluid or air in the peritoneal cavity ([Fig. 5]). The patient was kept fasting until bowel transit was re-established 2 days later. She was symptom-free by the postoperative third day. On day 5, she was discharged from the hospital. She is clinically well and symptom-free.

Fig. 5 CT scan with bowel opacification confirmed a sealed clip.

Delayed treatment of an iatrogenic colonic perforation with an over-the-scope clip is a feasible and effective technique that should be considered by expert endoscopists. However, the peritoneal cavity may become contaminated during the delay between perforation and definitive treatment.

Endoscopy_UCTN_Code_TTT_1AQ_2AG

Competing interests: None

• References

• 1 Donatelli G, Vergeau BM, Dritsas S et al. Closure with an over-the-scope-clip allows therapeutic ERCP to be safely performed after acute duodenal perforation during diagnostic endoscopic ultrasound. Endoscopy 2013; 45: E392-393
• 2 Dìez-Redonod P, Bianco JL, Lorenzo-Pelayo S et al. A novel system for endoscopic closure of iatrogenic colon perforations using the Ovesco clip and omental patch. Rev Esp Enferm Dig 2012; 104: 550-552