Removal of Over the Scope Clips (OTSC) with an Nd:YAG Laser

Abstract

Until recently there has been no technique available which reproducibly and safely allows endoscopic closures of penetrating defects within the digestive tract. With the new "over the scope clipping system" (OTSC system), which regarding design and function is similar to a bear-trap, a method is available for the endoscopic closure of fistulas and perforations. The OTSC-systems are designed for permanent placement. However, in the case of misplacement or the need to remove the clip after healing of the defect, a technique for destroying and removing the clip should be available. We demonstrate for the first time the successful removal of the deeply penetrating OTSC system by using the Nd:YAG-Laser in 3 cases: (i) after closure of an oesophageal fistula, (ii) after closure of a perforation of the distal common bile duct in the roof of the papilla and (iii) after clip misplacement in a case of a wide oesophagomediastinal fistula resulting in a severe oesophageal stenosis. Clinically relevant thermal lesions were not observed after the procedure. If clinically necessary, the OTSC-system can be safely removed by the Nd:YAG Laser in centres for interventional endoscopy. Because of the small number of cases the method must still be considered as experimental and requires further validation. This will be possible with the help of a newly established OTSC registry ( www.endodo.de ).

Description of a new, endoscopic technique to remove the over-the-scope-clip in an ex vivo porcine model (with video)

“…Very recently, a technique to remove the OTSC by using an Nd:YAG laser was shown in 3 patients. 13 In this case study, clinically relevant thermal lesions were not observed after the procedure, and the OTSC could be always removed.…”

“…In this scenario, the endoscopist might place the OTSC in the wrong position or the clip might be placed in a location that hampers additional endoscopic therapy, such as described in a case of cholangiocarcinoma where the OTSC inhibited treatment of the tumor by endoscopic photodynamic therapy. 13 In these circumstances, the OTSC may need to be removed. Thus, the availability of techniques to do so is important.…”

“…10 Various studies have demonstrated the utility of the OTSC system to close perforations as large as 20 mm. [11][12][13][14][15][16][17] In addition, the OTSC system has also been found useful to close fistulae and anastomotic leaks and to provide hemostasis. [18][19][20][21][22][23][24][25] However, a potential limitation of the OTSC system is that once it is deployed, it cannot be removed.…”

Clips for closure of full-thickness defects

“…As shown in F2 Figure 2, there are 3 types of Ovesco OTSC: "atraumatic" (blunt teeth, primarily designed for hemostasis), traumatic (with short sharp teeth designed for defect closure), and "gastric closure" (with longer teeth designed for improved tissue grip for full-thickness closure and NOTES applications). Because of the strength of OTSCs, they may be difficult (though not impossible [10][11][12][13][14]) to remove once deployed.…”

Novel endoscopic multi-firing-clip applicator for endoscopic closure of large colonic perforations

“…In this respect, although OTSC is reported to result in good clinical outcome following its use in endoscopic closure of perforations [18], additional cumbersome procedure is needed for clip removal; whilst TTSC may drop off following application [19].…”