Download PDF
Clin Colon Rectal Surg 2024; 37(05): 302-308
DOI: 10.1055/s-0043-1770944
Review Article

Assessment and Techniques for Endoscopic Closure

Ragavan Siddharthan
1   Capitol District Colon and Rectal Surgery Associated, Albany, New York
,
Peter Marcello
2   Department of Colon and Rectal Surgery, Lahey Hospital and Medical Center, Burlington, Massachusetts
› Author Affiliations
› Further Information
Also available at
    Permissions and Reprints

Abstract

Endoscopic closure is an essential technique to perform safe advanced endoscopy. Without appropriate closure of a defect, patients can experience spillage of fecal contents into the peritoneal cavity resulting in abdominal sepsis. The essential components to performing endoscopic closure are assessing the defect appropriately and choosing the correct closure technique. Assessing the defect involves five separate elements: timing, size, depth, shape, blood flow, and location in the colon or rectum. Understanding how each of these elements contributes toward a successful closure allows an endoscopist to choose the proper technique for closure. There have been many types of closure techniques described in the literature but the most common are through the scope clips, over the scope clips, and endoscopic suturing. There are advantages and disadvantages of each of these closure techniques. In this manuscript, we will discuss these common techniques as well as some additional techniques and the situations where they can be employed.

Keywords

endoscopic closure - endoscopic clips - endoscopic suturing


Publication History

Article published online:
19 July 2023

© 2023. Thieme. All rights reserved.

Thieme Medical Publishers, Inc.
333 Seventh Avenue, 18th Floor, New York, NY 10001, USA

 

  • References

  • 1 de Moura DTH, Sachdev AH, Thompson CC. Endoscopic full-thickness defects and closure techniques. Curr Treat Options Gastroenterol 2018; 16 (04) 386-405
    CrossrefPubMedGoogle Scholar
  • 2 Cho J, Sahakian AB. Endoscopic closure of gastrointestinal fistulae and leaks. Gastrointest Endosc Clin N Am 2018; 28 (02) 233-249
    CrossrefPubMedGoogle Scholar
  • 3 Noren ER, Wickham C, Lee SW. Current techniques for combined endoscopic and laparoscopic surgery (CELS). Ann Laparosc Endosc Surg 2019; 4: 77
    CrossrefPubMedGoogle Scholar
  • 4 Mann R, Gajendran M, Umapathy C. et al. Endoscopic management of complex colorectal polyps: current insights and future trends. Front Med (Lausanne) 2022; 8: 728704
    CrossrefPubMedGoogle Scholar
  • 5 Pohl H, Grimm IS, Moyer MT. et al. Clip closure prevents bleeding after endoscopic resection of large colon polyps in a randomized trial. Gastroenterology 2019; 157 (04) 977-984.e3
    CrossrefPubMedGoogle Scholar
  • 6 Rustagi T, McCarty TR, Aslanian HR. Endoscopic treatment of gastrointestinal perforations, leaks, and fistulae. J Clin Gastroenterol 2015; 49 (10) 804-809
    CrossrefPubMedGoogle Scholar
  • 7 Hafner J, Tuma F, Hoilat GJ, Marar O. Intestinal Perforation, in StatPearls. 2022. Treasure Island, FL:
    Google Scholar
  • 8 Arora G, Mannalithara A, Singh G, Gerson LB, Triadafilopoulos G. Risk of perforation from a colonoscopy in adults: a large population-based study. Gastrointest Endosc 2009; 69 (3 Pt 2): 654-664
    CrossrefPubMedGoogle Scholar
  • 9 Hassan C, Repici A, Sharma P. et al. Efficacy and safety of endoscopic resection of large colorectal polyps: a systematic review and meta-analysis. Gut 2016; 65 (05) 806-820
    CrossrefPubMedGoogle Scholar
  • 10 Tanaka S, Terasaki M, Kanao H, Oka S, Chayama K. Current status and future perspectives of endoscopic submucosal dissection for colorectal tumors. Dig Endosc 2012; 24 (Suppl. 01) 73-79
    CrossrefPubMedGoogle Scholar
  • 11 Csendes A, Braghetto I, León P, Burgos AM. Management of leaks after laparoscopic sleeve gastrectomy in patients with obesity. J Gastrointest Surg 2010; 14 (09) 1343-1348
    CrossrefPubMedGoogle Scholar
  • 12 Li YW, Lian P, Huang B. et al. Very early colorectal anastomotic leakage within 5 post-operative days: a more severe subtype needs relaparatomy. Sci Rep 2017; 7: 39936
    CrossrefPubMedGoogle Scholar
  • 13 Thomas MS, Margolin DA. Management of colorectal anastomotic leak. Clin Colon Rectal Surg 2016; 29 (02) 138-144
    Article in Thieme ConnectPubMedGoogle Scholar
  • 14 De Ceglie A, Hassan C, Mangiavillano B. et al. Endoscopic mucosal resection and endoscopic submucosal dissection for colorectal lesions: a systematic review. Crit Rev Oncol Hematol 2016; 104: 138-155
    CrossrefPubMedGoogle Scholar
  • 15 Yano T, Tanabe S, Ishido K. et al. Delayed perforation after endoscopic submucosal dissection for early gastric cancer: clinical features and treatment. World J Gastrointest Endosc 2016; 8 (08) 368-373
    CrossrefPubMedGoogle Scholar
  • 16 Gopalswamy N, Shenoy VN, Choudhry U. et al. Is in vivo measurement of size of polyps during colonoscopy accurate?. Gastrointest Endosc 1997; 46 (06) 497-502
    CrossrefPubMedGoogle Scholar
  • 17 Martínez F, Ruano J, Gómez M, Romero E. Polyp size estimation strategies during endoscopy procedures: a review. J Gastrointest Dig Syst 2015; (e-pub ahead of print). DOI: 10.4172/2161-069X.1000329.
    CrossrefPubMedGoogle Scholar
  • 18 Azzouz LL, Sharma S. Physiology, Large Intestine, in StatPearls. 2022. Treasure Island, FL:
    Google Scholar
  • 19 Toyonaga T, Nishino E, Man-I M, East JE, Azuma T. Principles of quality controlled endoscopic submucosal dissection with appropriate dissection level and high quality resected specimen. Clin Endosc 2012; 45 (04) 362-374
    CrossrefPubMedGoogle Scholar
  • 20 Burgess NG, Bassan MS, McLeod D, Williams SJ, Byth K, Bourke MJ. Deep mural injury and perforation after colonic endoscopic mucosal resection: a new classification and analysis of risk factors. Gut 2017; 66 (10) 1779-1789
    CrossrefPubMedGoogle Scholar
  • 21 Raju GS, Saito Y, Matsuda T, Kaltenbach T, Soetikno R. Endoscopic management of colonoscopic perforations (with videos). Gastrointest Endosc 2011; 74 (06) 1380-1388
    CrossrefPubMedGoogle Scholar
  • 22 Kopelman Y, Siersema PD, Bapaye A, Kopelman D. Endoscopic full-thickness GI wall resection: current status. Gastrointest Endosc 2012; 75 (01) 165-173
    CrossrefPubMedGoogle Scholar
  • 23 Winder JS, Pauli EM. Novel endoscopic modalities for closure of perforations, leaks, and fistula in the gastrointestinal tract. Tech Gastrointest Endosc 2019; 21: 109-114
    CrossrefPubMedGoogle Scholar
  • 24 Rex DK. Prophylactic clip closure clarified: the question is not whether to clip, but when. Gastroenterology 2019; 157 (05) 1190-1192
    CrossrefPubMedGoogle Scholar
  • 25 Pellise M, Burgess NG, Tutticci N. et al. Endoscopic mucosal resection for large serrated lesions in comparison with adenomas: a prospective multicentre study of 2000 lesions. Gut 2017; 66 (04) 644-653
    CrossrefPubMedGoogle Scholar
  • 26 Jabehdar Maralani P, Schieda N, Hecht EM. et al. MRI safety and devices: an update and expert consensus. J Magn Reson Imaging 2020; 51 (03) 657-674
    CrossrefPubMedGoogle Scholar
  • 27 Turan AS, Ultee G, Van Geenen EJM, Siersema PD. Clips for managing perforation and bleeding after colorectal endoscopic mucosal resection. Expert Rev Med Devices 2019; 16 (06) 493-501
    CrossrefPubMedGoogle Scholar
  • 28 Kantsevoy SV, Bitner M, Hajiyeva G. et al. Endoscopic management of colonic perforations: clips versus suturing closure (with videos). Gastrointest Endosc 2016; 84 (03) 487-493
    CrossrefPubMedGoogle Scholar
  • 29 Magdeburg R, Collet P, Post S, Kaehler G. Endoclipping of iatrogenic colonic perforation to avoid surgery. Surg Endosc 2008; 22 (06) 1500-1504
    CrossrefPubMedGoogle Scholar
  • 30 Yeh RW, Kaltenbach T, Soetikno R. Endoclips. Tech Gastrointest Endosc 2006; 8: 2-11
    CrossrefPubMedGoogle Scholar
  • 31 Mahmoud T, Wong Kee Song LM, Stavropoulos SN. et al. Initial multicenter experience using a novel endoscopic tack and suture system for challenging GI defect closure and stent fixation (with video). Gastrointest Endosc 2022; 95 (02) 373-382
    CrossrefPubMedGoogle Scholar
  • 32 Ponugoti PL, Rex DK. Clip retention rates and rates of residual polyp at the base of retained clips on colorectal EMR sites. Gastrointest Endosc 2017; 85 (03) 530-534
    CrossrefPubMedGoogle Scholar
  • 33 Tang SJ, Naga YM, Zhang S. Double-channel double-grasper technique in over-the-scope clip deployment. VideoGIE 2020; 5 (04) 141-143
    CrossrefPubMedGoogle Scholar
  • 34 Verlaan T, Voermans RP, van Berge Henegouwen MI, Bemelman WA, Fockens P. Endoscopic closure of acute perforations of the GI tract: a systematic review of the literature. Gastrointest Endosc 2015; 82 (04) 618-28.e5
    CrossrefPubMedGoogle Scholar
  • 35 Weiland T, Fehlker M, Gottwald T, Schurr MO. Performance of the OTSC System in the endoscopic closure of iatrogenic gastrointestinal perforations: a systematic review. Surg Endosc 2013; 27 (07) 2258-2274
    CrossrefPubMedGoogle Scholar
  • 36 Pauli EM, Delaney CP, Champagne B, Stein S, Marks JM. Safety and effectiveness of an endoscopic suturing device in a human colonic treat-and-resect model. Surg Innov 2013; 20 (06) 594-599
    CrossrefPubMedGoogle Scholar
  • 37 Kantsevoy SV, Bitner M, Mitrakov AA, Thuluvath PJ. Endoscopic suturing closure of large mucosal defects after endoscopic submucosal dissection is technically feasible, fast, and eliminates the need for hospitalization (with videos). Gastrointest Endosc 2014; 79 (03) 503-507
    Google Scholar
  • 38 Cai JX, Khashab MA, Okolo III PI, Kalloo AN, Kumbhari V. Full-thickness endoscopic suturing of staple-line leaks following laparoscopic sleeve gastrectomy. Endoscopy 2014; 46 (1, suppl 1 UCTN): E623-E624
    Article in Thieme ConnectPubMedGoogle Scholar
  • 39 Patil G, Iyer A, Dalal A, Maydeo A. The Usefulness of an Endoscopic OverStitch Suturing System for Managing Anastomotic Dehiscence–-a case report. GE Port J Gastroenterol 2020; 27 (06) 434-438
    CrossrefPubMedGoogle Scholar
  • 40 Halvax P, Diana M, Lègner A. et al. Endoluminal full-thickness suture repair of gastrotomy: a survival study. Surg Endosc 2015; 29 (11) 3404-3408
    CrossrefPubMedGoogle Scholar
  • 41 Beck DE, Karulf RE. Laparoscopic-assisted full-thickness endoscopic polypectomy. Dis Colon Rectum 1993; 36 (07) 693-695
    CrossrefPubMedGoogle Scholar
  • 42 Gorgun E, Benlice C, Abbas MA, Steele S. Experience in colon sparing surgery in North America: advanced endoscopic approaches for complex colorectal lesions. Surg Endosc 2018; 32 (07) 3114-3121
    CrossrefPubMedGoogle Scholar
  • 43 Loske G, Schorsch T, Müller C. Intraluminal and intracavitary vacuum therapy for esophageal leakage: a new endoscopic minimally invasive approach. Endoscopy 2011; 43 (06) 540-544
    Article in Thieme ConnectPubMedGoogle Scholar
  • 44 You YN, Hardiman KM, Bafford A. et al; On Behalf of the Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Rectal Cancer. Dis Colon Rectum 2020; 63 (09) 1191-1222
    CrossrefPubMedGoogle Scholar
  • 45 Khan K, Hunter IA, Manzoor T. Should the rectal defect be sutured following TEMS/TAMIS carried out for neoplastic rectal lesions? A meta-analysis. Ann R Coll Surg Engl 2020; 102 (09) 647-653
    CrossrefPubMedGoogle Scholar
  • 46 Brown C, Raval MJ, Phang PT, Karimuddin AA. The surgical defect after transanal endoscopic microsurgery: open versus closed management. Surg Endosc 2017; 31 (03) 1078-1082
    CrossrefPubMedGoogle Scholar
  • 47 Brown CJ, Hochman D, Raval MJ. et al. A multi-centre randomized controlled trial of open vs closed management of the rectal defect after transanal endoscopic microsurgery. Colorectal Dis 2019; 21 (09) 1025-1031
    CrossrefPubMedGoogle Scholar
  • 48 Pinto A, Miele V, Schillirò ML. et al. Spectrum of Signs of Pneumoperitoneum. Semin Ultrasound CT MR 2016; 37 (01) 3-9
    CrossrefPubMedGoogle Scholar
  • 49 Stapakis JC, Thickman D. Diagnosis of pneumoperitoneum: abdominal CT vs. upright chest film. J Comput Assist Tomogr 1992; 16 (05) 713-716
    CrossrefPubMedGoogle Scholar
  • 50 Kim SH, Shin SS, Jeong YY, Heo SH, Kim JW, Kang HK. Gastrointestinal tract perforation: MDCT findings according to the perforation sites. Korean J Radiol 2009; 10 (01) 63-70
    CrossrefPubMedGoogle Scholar