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Endoscopic suturing may be superior to clips for closure of colonic perforations
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Results from two retrospective studies recently published in Gastrointestinal Endoscopy present differing conclusions on the effectiveness of through-the-scope clips for endoscopic closure of iatrogenic colonic perforations, one of which suggests that endoscopic suturing may be a more effective strategy.
These results led experts from University of Michigan and Mayo Clinic to suggest that the appropriate strategy for perforation closure depends on a number of factors, including the perforation’s size and location, the availability and limitations of devices, operator skillset and costs.
Sergey V. Kantsevoy
“In the U.S. there are more than 14.2 million screening colonoscopies performed every year, with perforations occurring in as many as one out of every 1,000 — that’s 14,200 colon perforations,” Sergey V. Kantsevoy, MD, PhD, director of The Center for Therapeutic Endoscopy at Mercy Medical Center, said in a press release. “And colon perforations can occur during other abdominal procedures, such as the removal of colon polyps or colon resections, so determining the fastest, most effective way to close these perforations for the patient’s benefit is extremely important.”
Kantsevoy and colleagues analyzed data on all consecutive patients who had iatrogenic full-thickness colonic perforations closed with an endoscopic suturing device (Overstitch, Apollo Endosurgery; n = 16) or through-the-scope endoscopic clips (Resolution, Boston Scientific; n = 5) at Mercy Medical Center between 2009 and 2014.
They found that all five patients whose perforations were closed with clips had worsening of abdominal pain, four of whom required laparoscopy and one of whom required rescue colonoscopy with endoscopic suturing closure. In addition, just two of the patients whose perforations were closed with endoscopic suturing experienced abdominal pain, but complete and adequate closure was confirmed by diagnostic laparoscopy.
The researchers acknowledged the study is limited by its retrospective, single-center design and small patient population, and that larger prospective, multicenter studies are needed.
“Given what we have seen in this study, it appears that closing colon perforations by using endoscopic suturing is technically feasible, eliminates the need for rescue or emergency surgery and appears to be more effective than closure using endoscopic clips,” Kantsevoy said in the press release.
In the related study, researchers from the endoscopy division at the National Cancer Center Hospital in Tokyo performed a matched case–control study involving 24 patients who had endoscopic closure of perforations and 240 controls among a large cohort of patients (n = 935) who underwent colonic endoscopic submucosal dissection between 1998 and 2013. All but one of the 24 patients with perforations (96%) had successful closure using through-the-scope clips (EZ Clip and Long Clip, Olympus).
“Most notably, the studies ... provide discrepant results regarding the utility of [through-the-scope] clips for the management of iatrogenic colonic perforations ... despite similarities in mean perforation size (3.4 mm vs. 5 mm),” Ryan Law, DO, of the division of gastroenterology at University of Michigan, Ann Arbor, and Louis M. Wong Kee Song, MD, FASGE, of the division of gastroenterology and hepatology at Mayo Clinic, Rochester, Minn., wrote in a related editorial. “Although the study results are intriguing and hypothesis-generating, the two groups (clip vs. suturing) in the report by Kantsevoy et al are not comparable in our opinion, and the study is grossly underpowered to determine a clinically significant difference.”
Law and Wong Kee Song suggest that, “from a practical perspective,” through-the-scope clips are reasonable for perforations smaller than 1 cm that are recognized intraprocedurally and have viable margins, while more robust options like endoscopic suturing or over-the-scope clips may be more suitable for large, gaping perforations when accessible. – by Adam Leitenberger
References:
Kantsevoy SV, et al. Gastrointest Endosc. 2016;doi:10.1016/j.gie.2015.08.074.
Law R and Wong Kee Song LM. Gastrointest Endosc. 2016;doi:10.1016/j.gie.2016.04.040.
Takamaru H, et al. Gastrointest Endosc. 2016;doi:10.1016/j.gie.2016.01.014.
Disclosures: Kantsevoy reports he is a cofounder of and shareholder in Apollo Endosurgery. The other researchers and editorial authors report no relevant financial disclosures.