Abstract
Background and Aims
Endoscopic mucosal resection (EMR) poses a risk of iatrogenic colonic perforation. In this case, we discuss the endoscopic closure of a colonic perforation with sequential over-the-scope clips (OTSCs), one of which was deployed in retroflexion.
Methods
A 61-year-old patient presented for EMR of a transverse colon polyp. Lifting agent injection provided inadequate lift, so underwater EMR was performed with a hot snare. After en bloc polypectomy, a full-thickness perforation was found. We review our perforation closure technique, including an unsuccessful attempt with through-the-scope clips followed by successful closure with sequential OTSCs.
Results
Approximation of defect edges with through-the-scope clips was technically challenging because of location and width of the defect. Ultimately, the perforation was closed with 2 OTSCs. A retroflexed examination of the defect with gastroscope found a persistent defect along the posterior aspect. The remaining area was closed with a third OTSC deployed in retroflexion.
Conclusions
This case highlights use of sequential OTSCs, including one deployed in retroflexion to successfully close a large, full-thickness transverse colonic perforation following an EMR. We describe modified positioning of the OTSC that enabled more tissue acquisition with clip deployment. The patient did well postprocedurally, without need for surgical intervention.
Video
Introduction
Colonic perforation is an adverse event of both diagnostic and therapeutic colonoscopy with a pooled incidence estimate of 1% to 5%.1,2 We report the use of sequential over-the-scope clips (OTSCs), including one deployed in retroflexion in the transverse colon.
Case
A 61-year-old man underwent screening colonoscopy that revealed a 25-mm flat and multilobulated polyp in the transverse colon that was biopsied and tattooed. He was referred for endoscopic mucosal resection (EMR).
Procedure
Video 1 (available online at www.videogie.org) depicts the colonoscopy with perforation repair. The procedure was performed with the patient under monitored anesthesia care and the exclusive use of carbon dioxide insufflation. We identified the polyp with high-definition white-light and narrow-band imaging. We injected the lifting agent to the left and right borders of the polyp, which raised the lateral margins, although the central portion remained depressed. There was likely underlying fibrosis and scar tissue from the previous biopsy and tattoo. Therefore, we performed underwater EMR to further lift from the muscularis propria. A 20-mm hot snare was used for en bloc polypectomy. Postpolypectomy inspection revealed a 30-mm full-thickness perforation likely related to previous scarring, as shown in Figure 1.
Figure 1.
Postpolypectomy inspection after endoscopic mucosal resection revealed a full-thickness perforation in the transverse colon.
We attempted to close the defect with a zipper technique using through-the-scope clips (TTSCs), although maneuvering was difficult, given the location of the polyp at a turn and a defect spanning 2 colonic folds. Furthermore, we were concerned that TTSCs would close the defect superficially but would not grasp deeper tissue to truly close the perforation. Figure 2 depicts the challenges with TTSC closure.
Figure 2.
Perforation with through-the-scope clips was challenging given the wide defect located at a turn in the colon, making approximation challenging.
The TTSCs were removed to allow a second closure attempt. We were concerned that the therapeutic endoscope might not reach the proximal transverse colon to perform endoscopic suturing. Therefore, we selected a 14/6t OTSC. We intentionally modified the positioning of the OTSC compared with the standard recommendations by the manufacturer. One study mentioned a 6-mm cap depth may be appropriate for perforations because it enables more tissue acquisition with deployment.3 The OTSC was pushed forward so the clear securing fixtures (yellow arrows) and clip (red arrow) were visible (Fig. 3A) rather than standard positioning with these fixtures flush against the scope and out of view (Fig. 3B). Care must be taken with advancement of the scope because this OTSC positioning can decrease endoscopic visualization and has increased risk of cap dislodgement. Of note, the suction technique carries a risk of catching external structures and can cause luminal restriction.4 After the first OTSC was placed, a second 14/6t OTSC was used to successfully close the remaining defect.
Figure 3.
Over-the-scope clips (OTSCs) were used to close the perforation. A, The first OTSC had modified positioning where the clip was pushed forward so the clear securing fixtures (yellow arrows) and clip (red arrow) were visible. B, Note the normal positioning of the second OTSC with the clear securing fixtures and clip flush against the scope and not clearly visualized.
The colonoscope was exchanged for a gastroscope, which was navigated past the perforation site, confirming luminal patency. Retroflexion in the transverse colon revealed a persistent mucosal defect (Fig. 4). We chose an 11/6t OTSC to close the remaining defect, as the smaller size would be more likely to pass the narrowed lumen at the closure site. The 11/6t OTSC was deployed in retroflexion to complete perforation closure. To our knowledge, retroflexed deployment of OTSC has not been previously performed and documented in the right-sided colon. Final examination showed a successful perforation closure (Fig. 5A). Luminal patency was confirmed because the scope was able to pass the repair site (Fig. 5B). The duration of procedure was 72 minutes. The surgical pathology of the polyp eventually returned as a tubular adenoma with intact muscularis propria.
Figure 4.
A mucosal defect was noted on retroflexed examination of transverse colon repair site. This area was closed with a third over-the-scope clip deployed in retroflexion.
Figure 5.
Successful closure of the perforation with sequential over-the-scope clips (A), one of which was deployed in retroflexion. After closure, luminal patency was confirmed by smooth passage of EGD scope past the repair site (B).
Outcome
Postprocedurally, the patient did not report abdominal pain and remained hemodynamically stable. He was conservatively managed with intravenous zosyn and fluids, and kept nil per os. Computed tomography of the abdomen and pelvis with oral and intravenous contrast did not show contrast leak or persistent perforation. The surgery team evaluated the patient and did not recommend surgical intervention. The patient was discharged within 48 hours of the procedure with a 7-day course of oral amoxicillin/clavulanate.
Patient Consent
The patient was informed and consented to the publication of this case report.
Disclosure
The following authors disclosed financial relationships: S. G. Krishna: Research grant funding from Mauna Kea Technologies and Taewoong Medical, USA. All other authors disclosed no financial relationships.
Supplementary data
Endoscopic closure of full-thickness transverse colon perforation with sequential over-the-scope clips including retroflexed deployment.
References
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Associated Data
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Supplementary Materials
Endoscopic closure of full-thickness transverse colon perforation with sequential over-the-scope clips including retroflexed deployment.