The endoloop–clips technique for closure of large iatrogenic colonic perforations

We read with considerable interest the excellent review article of Panteris et al. [1] on colonic perforation after diagnostic and therapeutic colonoscopy. In the section on endoscopic treatment, they report the successful use of endoclipping to seal visible or suspected immediate perforations in order to avoid abdominal contamination and subsequent operative management, noting that in all cases the defect was less than 10 mm in size. The limitation of the application of this technique to defects of such small size reflects the fact that the aperture between long clip arms is only 12 mm, making it almost impossible to use endoclipping for the treatment of large defects.

However, we believe that the review would have been more comprehensive if the endoloop–clips technique had been reported as a reliable method for the closure of larger defects. Use of this technique requires a two-channel endoscope. An endoloop (MAJ-254, diameter 30 mm; Olympus, Tokyo, Japan) is inserted through one of the working channels. One side of the endoloop snare is fixed near the upper or lower margin of the defect by a metal clip deployed using an applicator device. The maneuver is repeated to anchor the other side of the same loop snare at the other margin of the defect. The endoloop is tightened slowly, resulting in approximation of the borders of the perforation. Several clips are required to bring the margins together and close the defect.

The endoloop–clips technique was first used by Endo et al. [2] to close large mucosal defects in 32 patients after endoscopic mucosal resection (EMR) of gastric mucosal tumors. In the same year, Matsuda et al. [3] reported using the same method to close a large defect (5 mm in diameter) after EMR of a laterally spreading colorectal tumor. In our unit, we recently treated a large iatrogenic rectal perforation (diameter 3mm) using the endoloop–clips technique [4].

Therefore we believe that the endoloop–clips technique, which mimics a surgical suture, is a promising method that endoscopists should become familiar with, as it can be used safely and efficiently to close large iatrogenic perforations, reducing the need for surgical intervention and the cost of a long hospitalization.

Competing interests: None

References

• 1 Panteris V, Haringsma J, Knipers E J. Colonoscopy perforation rate, mechanisms, and outcome: from diagnostic to therapeutic colonoscopy.  Endoscopy. 2009;  41 941-951
• 2 Endo M, Inomata M, Terni T. et al . New endoscopic technique to close large mucosal defects after endoscopic mucosal resection in patients with gastric mucosal tumors.  Dig Endosc. 2004;  16 372-375
• 3 Matsuda T, Fujii T, Emura F. et al . Complete closure of a large defect after EMR of a lateral spreading colorectal tumor when using a two channel colonoscope.  Gastrointest Endosc. 2004;  60 836-838
• 4 Katsinelos P, Kountouras J, Chatzimavroudis G. et al . Endoscopic closure of a large rectal perforation using endoloop/clips technique.  Acta Gastroenterol Belg. 2009;  72 357-359