Evaluating long-term attachment of two different endoclips in the human gastrointestinal tract

AIM:To evaluate the long-term attachment of two types of endoclips in the human gastrointestinal tract. METHODS:In this prospective observational study,endoclips were placed and followed-up during endoscopies or using fluoroscopic images as part of a pro s pective feasibility study evaluating external beam radiotherapy (EBRT,wk 1-3) followed by high dose rate brachytherapy (HDRBT with an endoluminal app licator once a week for 3 wk,wk 9-11) in medically inoperablerectal cancer patients. Initially,the type and number of endoclips were chosenrandomly and later refined to 1 Resolution clip (Microvasive) proximal and 2 Quickclips (Olympus) distal to the tumor. Nine consecutive patients from between September 2007 and August 2008 were analyzed. Retention rates were evaluated over three different observational periods [period 1:pre-HDRBT (wk-2-8),period 2:during HD RBT (wk 9-11) and period 3:post-HDRBT (wk 1216)]. RESULTS:In this study,a total of 44 clips were placed during endoscopy,either at the beginning or at the end of period 1. The Resolution clip had a higher overall retention rate than the Quickclip (P = 0.01). After a median period of 81 d after placement (in period 1),longterm retention rates for the Resolution clip and Quickclip clip were 67% and 35% respectively. CONCLUSION:The Resolution clip has a high retention rate and is useful in situations where long-term attachment to the human gastrointestinal mucosa is warranted.

Usefulness of tumor traction with a snare and endoclips in gastric submucosal tumor resection:a propensity-score-matching analysis

Background:Endoscopic resection,including endoscopic submucosal dissection(ESD)and endoscopic full-thickness resection(EFR),was used to resect small gastric submucosal tumors(SMTs).Our team explored a method of tumor traction using a snare combined with endoclips to assist in the resection of SMTs.This study aims to explore the safety and effectiveness of the method.Methods:This research performed a propensity-score-matching(PSM)analysis to compare ESD/EFR assisted by a snare combined with endoclips(ESD/EFR with snare traction)with conventional ESD/EFR for the resection of gastric SMTs.Comparisons were made between the two groups,including operative time,en bloc resection rate,perioperative complications,and operation-related costs.Results:A total of 253 patients with gastric SMTs resected between January 2012 and March 2019 were included in this study.PSM yielded 51 matched pairs.No significant differences were identified between the two groups in perioperative complications or the costs of disposable endoscopic surgical accessories.However,the ESD/EFR-with-snare-traction group had a shorter median operative time(39 vs 60 min,P=0.005)and lower rate of en bloc resection(88.2%vs 100%,P¼0.027).Conclusions:ESD/EFR with snare traction demonstrated a higher efficiency and en bloc resection rate for gastric SMTs,with no increases in perioperative complications and the costs of endoscopic surgical accessories.Therefore,the method seems an appropriate choice for the resection of gastric SMTs.

Primary endoscopic approximation suture under cap-assisted endoscopy of an ERCP-induced duodenal perforation

Duodenal perforation during endoscopic retrograde cholangiopancreatography(ERCP) is a rare complication,but it has a relatively high mortality risk.Early diagnosis and prompt management are key factors for the successful treatment of ERCP-related perforation.The management of perforation can initially be conservative in cases resulting from sphincterotomy or guide wire trauma.However,the current standard treatment for duodenal free wall perforation is surgical repair.Recently,several case reports of endoscopic closure techniques using endoclips,endoloops,or fully covered metal stents have been described.We describe four cases of iatrogenic duodenal bulb or lateral wall perforation caused by the scope tip that occurred during ERCP in tertiary referral centers.All the cases were simply managed by endoclips under transparent capassisted endoscopy.Based on the available evidence and our experience,endoscopic closure was a safe and feasible method even for duodenoscope-induced perforations.Our results suggest that endoscopists may be more willing to use this treatment.

Endoclipping treatment of life-threatening rectal bleeding after prostate biopsy

Rectal bleeding is frequently seen in patients undergoing transrectal ultrasound(TRUS)-guided multiple biopsy of the prostate,but is usually mild and stops spontaneously.We report what is believed to be the first case of life-threatening rectal bleeding following this procedure,which was successfully treated by endoscopic intervention through placement of three clips on the sites of bleeding.This case emphasizes endoscopic intervention associated with endoclipping as a safe and effective method to achieve hemostasis in massive rectal bleeding after prostate biopsy.Additionally,current data on the complications of the TRUS-guided multiple biopsy of the prostate and the options for treating fulminant rectal bleeding, a consequence of this procedure,are described.

Migrated endoclip and stone formation after cholecystectomy:A new danger of acute pancreatitis

Endoclip migration into the common bile duct following laparoscopic cholecystectomy (LC) is an extremely rare complication. Migrated endoclip into the common bile duct can cause obstruction,serve as a nidus for stone formation,and cause cholangitis. We report a case of obstructive jaundice and acute biliary pancreatitis due to choledocholithiasis caused by a migrated endoclip 6 mo after LC. The patient underwent early endoscopic retrog-rade cholangiopancreatography (ERCP) with endoscopic sphincterotomy and stone extraction.

Treatment of a duodenal perforation secondary to an endoscopic sphincterotomy with clips

Perforation is one of the most serious complications of endoscopic sphincterotomy (ES) necessitating immediate surgical intervention. We present a case of successful management of such a complication with endoclipping. A85-year-old woman developed duodenal perforation after ES. The perforation was identified early and its closure was achieved using three metallic clips in a single session.There was no procedure-related morbidity or complications and our patient was discharged from hospital 10 d later.Endoclipping of duodenal perforation induced by ES is a safe, effective and alternative to surgery treatment.

Endotherapy of leaks and fistula

Perforations, leaks and fistula involving gastrointestinal(GI) tract are increasing encountered in clinical practice. There is a changing paradigm for their management with surgical approach being replaced by conservative approach including endoscopic therapy. Clips(through the scope and over the scope) and covered stent are front runners for endotherapy for GI leaks and fistula.Over the scope clips introduced recently, can treat larger defects compared to through the scope clips. Covered stents are suited for larger defects and those associated with luminal narrowing. However cervical esophagus, gastro-esophageal junction, stomach and right colonic lesions may be better for clip therapy rather than stenting. Recent developments in this field include use of endovac therapy which consists of a sponge with suction device, biodegradable stent, use of fibrin glue and some endo-suturing device. Conservative therapy with no surgical or endoscopic intervention, may be suitable for a small subset of patients. An algorithm based on location, size of defect, associated stricture, infection and available expertise needs to be developed to reduce the mortality and morbidity of this difficult clinical problem.

Unexpected endoscopic full-thickness resection of a duodenal neuroendocrine tumor

A 57-year-old man underwent endoscopy for investigation of a duodenal polyp. Endoscopy revealed a hemispheric submucosal tumor, about 5 mm in diameter, in the anterior wall of the duodenal bulb. Endoscopic biopsy disclosed a neuroendocrine tumor histologically, therefore endoscopic mucosal resection was conducted. The tumor was effectively and evenly elevated after injection of a mixture of 0.2% hyaluronic acid and glycerol at a ratio of 1:1 into the submucosal layer. A small amount of indigo-carmine dye was also added for coloration of injection fluid. The lesion was completely resected en bloc with a snare after submucosal fluid injection. Immediately, muscle-fiber-like tissues were identified in the marginal area of the resected defect above the blue-colored layer, which suggested perforation. The defect was completely closed with a total of 9 endoclips, and no symptoms associated with peritonitis appeared thereafter. Histologically, the horizontal and vertical margins of the resected specimen were free of tumor and muscularis propria was also seen in the resected specimen. Generally, endoscopic mucosal resection is considered to be theoretically successful if the mucosal defect is colored blue. The blue layer in this case, however, had been created by unplanned injection into the subserosal rather than the submucosal layer.