A comprehensive approach to the management of acute endoscopic perforations (with videos)

Emergencies after endoscopic procedures

“…Stents can also be used in benign perforation, and removed 4-12 weeks later. Several endoscopic suturing prototypes were developed in the context of NOTES, anti-reflux and bariatric procedures [90,100] namely: T-tags (Ethicon Endo-Surgery and Cook Endoscopy), Overstitch (Apollo Endosurgery), pursed-string-suturing device (LSI Solutions), flexible endostitch (Covidien), NDO plicator (NDOSurgicalInc), flexible stapler (Power Medical Interventions), nevertheless its application remains limited in humans, and some of them only tested in animal models.…”

“…The rationale for that is multifactorial [1,90]. A recent review by Baron et al pointed out some main commandments of acute endoscopic perforation: (1) prompt recognition (preferably during the procedure) is essential to improve outcome; (2) extraluminal air does not automatically mean the need for surgery as it is not infectious and is not necessarily proportional to the size of the perforation; (3) extraluminal air under pressure is a medical emergency; (4) residual extraluminal air may persist without clinical significance; (5) perforations tend to close after drainage or diversion of luminal contents; (6) failed endoscopic closure generally requires surgical intervention.…”

“…The needle should be removed but the plastic sheath is left in situ to allow continuous decompression of the peritoneal cavity, while the procedure resumes and endoscopic intervention is ongoing even under air insufflation (Fig. 4) [5,90,93].…”

“…Initial series showed success with endoclips for small perforations [111,112], in the absence of peritoneal irritation. Subsequently also diagnostic, large perforations, in the presence of free air or moderately inflammatory signs, were also successfully treated with multiple clipping, OTSC or even band ligation [90]. Bowel preparation status is in general an important factor that may influence clinical management.…”

Over-the-scope clip for a pharyngeal perforation caused by a self-inflicted stab wound to the neck

“…This unique case suggests that an OTSC can be easily and successfully deployed in the hypopharynx, as in other gastrointestinal locations [3], despite the narrow operating space, and is associated with mild odynophagia. The OTSC expands the possible treatment options for minimally invasive flexible endoscopic closure of accidental and iatrogenic pharyngeal perforations that are potentially devastating [4] and difficult to treat with standard through-the-scope clips, and which may otherwise require prolonged conservative treatment or surgical intervention [5].…”