Management of gastrointestinal tract perforations

Abstract

Digestive endoscopy has evolved from primary diagnosis to extensive therapeutic approaches for the management of gastrointestinal diseases. Increased health awareness has encouraged more people to undergo endoscopic examinations. For these reasons, the absolute number of iatrogenic perforations is likely to increase. Because of the very low incidence of perforations, clinicians are not always prepared or experienced in cases of unexpectedly encountered perforations during diagnostic or therapeutic endoscopic procedures. In this study, the proper approach to handling perforations is discussed including selection of endoscopic devices, endoscopic closure procedures, and management of patients after a perforation occurs in the gastrointestinal tract.

Diagnosis and management of duodenal perforations: a narrative review

“…Through-the-scope clips (TTSC) can be used for endoscopic closure of small duodenal perforations. Linear perforations <1 cm are most suitable for the use of TTSC [50,51].…”

“…Self-expandable metal stents (SEMS) are alternative endoscopic treatment options for duodenal perforations [50,51,54].…”

Endoscopic Management of Iatrogenic Colon Perforation

“…The supervisor or expert endoscopist should decide carefully and promptly whether to observe, perform endoscopic closure, or perform surgery. 19…”

“…The decision of endoscopic closure should be made taking into account the quality of bowel preparation; time to diagnosis; comorbidities; clinical stability and symptoms; and endoscopic factors such as the available devices, endoscopist expertise, and type and size of the perforation. 1,19,20 The European Society of Gastrointestinal Endoscopy guidelines recommend considering endoscopic closure if the bowel is clean within 4 h of colon perforation. 20 Fujishiro et al 21 stated that there are four criteria for closing an acute iatrogenic perforation with metallic clips: (1) the perforation must be <1 cm; (2) the gastrointestinal (GI) tract must be as clean as possible; (3) the procedure must be conducted by an expert endoscopist; and (4) there should be no deterioration of clinical symptoms or laboratory indices, which should be monitored by an experienced surgeon.…”

“…However, most cases of perforations occurred during therapeutic colonoscopy and most of the perforations were small. 25 The following are technical tips for the use of TTSCs for iatrogenic perforations: 19,22 (1) Position the wide-open clip across the defect at a 90° angle. (2) Fix the clip arms on the tissue surrounding the defect.…”