BACKGROUND The over-the-scope clip(OTSC)system has been increasingly utilized as a nonsurgical option to endoscopically manage refractory gastrointestinal(GI)hemorrhage,perforations/luminal defects and fistulas.Limite...BACKGROUND The over-the-scope clip(OTSC)system has been increasingly utilized as a nonsurgical option to endoscopically manage refractory gastrointestinal(GI)hemorrhage,perforations/luminal defects and fistulas.Limited data exist evaluating the efficacy and safety of OTSC.AIM To determine the clinical success and adverse event(AE)rates of OTSC across all GI indications.METHODS A PubMed search was conducted for eligible articles describing the application of the OTSC system for any indication in the GI tract.Any article or case series reporting data for less than 5 total patients was excluded.The primary outcome was the rate of clinical success.Secondary outcomes included:Technical success rate,OTSC-related AE rate and requirement for surgical intervention despite-OTSC placement.Pooled rates(per-indication and overall)were calculated as the number of patients with the event of interest divided by the total number of patients.RESULTS A total of 85 articles met our inclusion criteria(n=3025 patients).OTSC was successfully deployed in 94.4%of patients(n=2856/3025).The overall rate of clinical success(all indications)was 78.4%(n=2371/3025).Per-indication clinical success rates were as follows:(1)86.0%(1120/1303)for GI hemorrhage;(2)85.3%(399/468)for perforation;(3)55.8%(347/622)for fistulae;(4)72.6%(284/391)for anastomotic leaks;(5)92.8%(205/221)for defect closure following endoscopic resection(e.g.,following endoscopic mucosal resection or endoscopic submucosal dissection);and(6)80.0%(16/20)for stent fixation.AE’s related to the deployment of OTSC were only reported in 64 of 85 studies(n=1942 patients),with an overall AE rate of 2.1%(n=40/1942).Salvage surgical intervention was required in 4.7%of patients(n=143/3025).CONCLUSION This systematic review demonstrates that the OTSC system is a safe and effective endoscopic therapy to manage GI hemorrhage,perforations,anastomotic leaks,defects created by endoscopic resections and for stent fixation.Clinical success in fistula management appears limited.Further studies,including randomized controlled trials comparing OTSC with conventional and/or surgical therapies,are needed to determine which indication(s)are the most effective for its use.展开更多
BACKGROUND Endoscopic resection of duodenal subepithelial lesions(SELs)is a difficult procedure with a high risk of perforation.At present,dealing with perforation after endoscopic resection of duodenal SELs is still ...BACKGROUND Endoscopic resection of duodenal subepithelial lesions(SELs)is a difficult procedure with a high risk of perforation.At present,dealing with perforation after endoscopic resection of duodenal SELs is still considered a great challenge.AIM To evaluate the effectiveness and safety of an over-the-scope clip(OTSC)in the treatment of perforation post-endoscopic resection of duodenal SELs.METHODS From May 2015 to November 2019,18 patients with perforation following endoscopic resection of duodenal SELs were treated with OTSCs.Data comprising the rate of complete resection,closure of intraprocedural perforation,delayed bleeding,delayed perforation,and postoperative infection were extracted.RESULTS The rate of complete removal of duodenal SELs and successful closure of the perforation was 100%.The median perforation size was 1 cm in diameter.Seventeen patients had minor intraoperative bleeding,while the remaining 1 patient had considerable amount of bleeding during the procedure.Seven patients had postoperative abdominal infections,of which 1 patient developed an abscess in the right iliac fossa and another patient developed septic shock.All 18 patients recovered and were discharged.No delayed bleeding or perforation was reported.The mean time taken to resume normal diet after the procedure was 6.5 d.The mean postoperative hospital stay was 9.5 d.No residual or recurrent lesions were detected during the follow-up period(15-66 mo).CONCLUSION Closing a perforation after endoscopic resection of duodenal SELs with OTSCs seems to be an effective and reasonably safe therapeutic method.展开更多
AIM: To retrospectively review the results of over-thescope clip (OTSC) use in our hospital and to examine the feasibility of using the OTSC to treat perforations after endoscopic submucosal dissection (ESD). METHODS:...AIM: To retrospectively review the results of over-thescope clip (OTSC) use in our hospital and to examine the feasibility of using the OTSC to treat perforations after endoscopic submucosal dissection (ESD). METHODS: We enrolled 23 patients who presented with gastrointestinal (GI) bleeding, fistulae and perforations and were treated with OTSCs (Ovesco Endoscopy GmbH, Tuebingen, Germany) between November 2011 and September 2012. Maximum lesion size was defined as lesion diameter. The number of OTSCs to be used per patient was not decided until the lesion was completely closed. We used a twin grasper (Ovesco Endoscopy GmbH, Tuebingen, Germany) as a grasping device for all the patients. A 9 mm OTSC was chosen for use in the esophagus and colon, and a 10 mm device was used for the stomach, duodenum and rectum. The overall success rate and complications were evaluated, with a particular emphasis on patients who had undergone ESD due to adenocarcinoma. In technical successful cases we included not only complete closing by using OTSCs, but also partial closing where complete closure with OTSCs is almost difficult. In overall clinical successful cases we included only complete closing by using only OTSCs perfectly. All the OTSCs were placed by 2 experienced endoscopists. The sites closed after ESD included not only the perforation site but also all defective ulcers sites.RESULTS: A total of 23 patients [mean age 77 years (range 64-98 years)] underwent OTSC placement during the study period. The indications for OTSC placement were GI bleeding (n = 9), perforation (n = 10), fistula (n = 4) and the prevention of post-ESD duodenal artificial ulcer perforation (n = 1). One patient had a perforation caused by a glycerin enema, after which a fistula formed. Lesion closure using the OTSC alone was successful in 19 out of 23 patients, and overall success rate was 82.6%. A large lesion size (greater than 20 mm) and a delayed diagnosis (more than 1 wk) were the major contributing factors for the overall unsuccessful clinical cases. The location of the unsuccessful lesion was in the stomach. The median operation time in the successful cases was 18 min, and the average observation time was 67 d. During the observation period, none of the patients experienced any complications associated with OTSC placement. In addition, we successfully used the OTSC to close the perforation site after ESD in 6 patients. This was a single-center, retrospective study with a small sample size. CONCLUSION: The OTSC is effective for treating GI bleeding, fistulae as well as perforations, and the OTSC technique proofed effective treatment for perforation after ESD.展开更多
AIM: To determine the outcome of the management of iatrogenic gastrointestinal tract perforations treated by over-the-scope clip(OTSC) placement.METHODS: We retrospectively enrolled 20 patients(13 female and 7 male; m...AIM: To determine the outcome of the management of iatrogenic gastrointestinal tract perforations treated by over-the-scope clip(OTSC) placement.METHODS: We retrospectively enrolled 20 patients(13 female and 7 male; mean age: 70.6 ± 9.8 years) in eight high-volume tertiary referral centers with upper or lower iatrogenic gastrointestinal tract perforation treated by OTSC placement. Gastrointestinal tract perforation could be with oval-shape or with round-shape. Ovalshape perforations were closed by OTSC only by suction and the round-shape by the "twin-grasper" plus suction. RESULTS: Main perforation diameter was 10.1 ± 4.3 mm(range 3-18 mm). The technical success rate was 100%(20/20 patients) and the clinical success rate was 90%(18/20 patients). Two patients(10%) who did not have complete sealing of the defect underwent surgery. Based upon our observations we propose two types of perforation: Round-shape "type-1 perforation" and oval-shape "type-2 perforation". Eight(40%) out of the 20 patients had a type-1 perforation and 12 patients a type-2(60%). CONCLUSION: OTSC placement should be attempted after perforation occurring during diagnostic or therapeutic endoscopy. A failed closure attempt does not impair subsequent surgical treatment.展开更多
AIM To evaluate rebleeding, primary failure(PF) and mortality of patients in whom over-the-scope clips(OTSCs) were used as first-line and second-line endoscopic treatment(FLET, SLET) of upper and lower gastrointestina...AIM To evaluate rebleeding, primary failure(PF) and mortality of patients in whom over-the-scope clips(OTSCs) were used as first-line and second-line endoscopic treatment(FLET, SLET) of upper and lower gastrointestinal bleeding(UGIB, LGIB).METHODS A retrospective analysis of a prospectively collected database identified all patients with UGIB and LGIB in a tertiary endoscopic referral center of the University of Freiburg, Germany, from 04-2012 to 05-2016(n= 93) who underwent FLET and SLET with OTSCs. The complete Rockall risk scores were calculated from patients with UGIB. The scores were categorized as < or ≥ 7 and were compared with the original Rockall data. Differences between FLET and SLET were calculated. Univariate and multivariate analysis were performed to evaluate the factors that influenced rebleeding after OTSC placement.RESULTS Primary hemostasis and clinical success of bleeding lesions(without rebleeding) was achieved in 88/100(88%) and 78/100(78%), respectively. PF was significantly lower when OTSCs were applied as FLET compared to SLET(4.9% vs 23%, P = 0.008). In multivariate analysis, patients who had OTSC placement as SLET had a significantly higher rebleeding risk compared to those who had FLET(OR 5.3; P = 0.008). Patients with Rockall risk scores ≥ 7 had a significantly higher in-hospital mortality compared to those with scores < 7(35% vs 10%, P = 0.034). No significant differences were observed in patients with scores < or ≥ 7 in rebleeding and rebleeding-associated mortality.CONCLUSION Our data show for the first time that FLET with OTSC might be the best predictor to successfully prevent rebleeding of gastrointestinal bleeding compared to SLET. The type of treatment determines the success of primary hemostasis or primary failure.展开更多
This paper reports our experience with a new overthe-scope clip in the setting of recurrent bleeding and oesophageal fistula. We treated five patients with the over-the-scope Padlock Clip?. It is a nitinol ring, with ...This paper reports our experience with a new overthe-scope clip in the setting of recurrent bleeding and oesophageal fistula. We treated five patients with the over-the-scope Padlock Clip?. It is a nitinol ring, with six inner needles preassembled on an applicator cap, thumb press displaced by the Lock-It? delivery system. The trigger wire is located alongside the shaft of the endoscope, and does not require the working channel. Three patients had recurrent bleeding lesions(bleeding rectal ulcer, post polypectomy delayed bleeding and duodenal Dieulafoy's lesion) and two patients had a persistent respiratory-esophageal fistula. In all patients a previous endoscopic attempt with standard techniques had been useless. All procedures were conducted under conscious sedation but for one patient that required general anaesthesia due to multiple comorbidities. We used one Padlock Clip? for each patient in a single session. Simple suction was enough in all of our patients to obtain tissue adhesion to the instrument tip. A remarkably short application time was recorded for all cases(mean duration of the procedure: 8 min). We obtained technical and immediate clinical success for every patient. No major immediate, early or late(within 24 h, 7 d or 4 wk) adverse events were observed, over follow-up durations lasting a mean of 109.4 d. One patient, treated for duodenal bulb bleeding from a Dieulafoy's lesion, developed signs of mild pancreatitis 24 h after the procedure. The new over-the-scope Padlock Clip? seems to be simple to use and effective in different clinical settings, particularly in "difficult" scenarios, like recurrent bleeding and respiratory-oesophageal fistulas.展开更多
An ileal pouch fistula is an uncommon complication after an ileal pouch anal anastomosis. Most patients who suffer from an ileal pouch fistula will need surgical intervention. However, the surgery can be invasive and ...An ileal pouch fistula is an uncommon complication after an ileal pouch anal anastomosis. Most patients who suffer from an ileal pouch fistula will need surgical intervention. However, the surgery can be invasive and has a high risk compared to endoscopic treatment. The over-the-scope clip(OTSC) system was initially developed for hemostasis and leakage closure in the gastrointestinal tract during flexible endoscopy. There have been many successes in using this approach to apply perforations to the upper gastrointestinal tract. However, this approach has not been used for ileal pouch fistulas until currently. In this report, we describe one patient who suffered a leak from the tip of the "J" pouch and was successfully treated with endoscopic closure via the OTSC system. A 26-year-old male patient had an intestinal fistula at the tip of the "J" pouch after an ileal pouch anal anastomosis procedure. He received endoscopic treatment via OTSC under intravenous anesthesia, and the leak was closed successfully. Endoscopic closure of a pouch fistula could be a simpler alternative to surgery and could help avoid surgeryrelated complications.展开更多
Endoscopic management of leakages and perforations of the upper gastrointestinal tract has gained great importance as it avoids the morbidity and mortality of surgical intervention.In the past years,covered selfexpand...Endoscopic management of leakages and perforations of the upper gastrointestinal tract has gained great importance as it avoids the morbidity and mortality of surgical intervention.In the past years,covered selfexpanding metal stents were the mainstay of endoscopic therapy.However,two new techniques are now available that enlarge the possibilities of defect closure:endoscopic vacuum therapy(EVT),and over-the-scope clip(OTSC).EVT is performed by mounting a polyurethane sponge on a gastric tube and placing it into the leakage.Continuous suction is applied via the tube resulting in effective drainage of the cavity and the induction of wound healing,comparable to the application of vacuum therapy in cutaneous wounds.The system is changed every 3-5 d.The overall success rate of EVT in the literature ranges from 84%to 100%,with a mean of 90%;only few complications have been reported.OTSCs are loaded on a transparent cap which is mounted on the tip of a standard endoscope.By bringing the edges of the perforation into the cap,by suction or by dedicated devices,such as anchor or twin grasper,the OTSC can be placed to close the perforation.For acute endoscopy associated perforations,the mean success rate is 90%(range:70%-100%).For other types of perforations(postoperative,other chronic leaks and fistulas)success rates are somewhat lower(68%,and59%,respectively).Only few complications have been reported.Although first reports are promising,further studies are needed to define the exact role of EVT and OTSC in treatment algorithms of upper gastrointestinal perforations.展开更多
Over-the-scope clip(OTSC) system is becoming a new reliable technique which is available for the endoscopic closure of fistulas, bleeding, perforations and so on. We describe the case of a patient with a nonhealing ga...Over-the-scope clip(OTSC) system is becoming a new reliable technique which is available for the endoscopic closure of fistulas, bleeding, perforations and so on. We describe the case of a patient with a nonhealing gastrocutaneous fistula after esophagectomy for esophageal squamous cell carcinoma which was successfully closed using an OTSC system. This is the first report of the use of OTSC to treat a nonhealing gastrocutaneous fistula successfully after esophagectomy. We believe our experience will give such patients an ideal way to cure the fistula without suffering too much and also explore new application of OTSC.展开更多
Gastrointestinal (GI) defects such as fistulas and leaks can be potentially closed endoscopically using hemo-clips and loops. However, hemoclips may not allow for closure of large defects and they do not exert enough ...Gastrointestinal (GI) defects such as fistulas and leaks can be potentially closed endoscopically using hemo-clips and loops. However, hemoclips may not allow for closure of large defects and they do not exert enough tensile force to keep fibrotic defects larger than 5 mm approximated. Herein we present a case of successful endoscopic closure of a gastrocolic fistula in a severely malnourished patient with complex post-surgical upper GI anatomy. We strongly believe that this device is a major breakthrough for the management of various types of discontinuity defects or fistulas. In addition, we show the usefulness of placing a direct jejunostomy using the double balloon enteroscopy (DBE) technique during the same procedure. The concept of providing direct jejunal feedings while allowing for upper gas-trointestinal bowel rest to promote the healing of the minimally invasive endoscopic operation is novel. Thus, our case is unique and exemplifies the utility of mini-mally invasive endoscopic endoluminal surgery.展开更多
AIM: To investigate the efficacy and clinical outcome of patients treated with an over-the-scope-clip(OTSC) system for severe gastrointestinal hemorrhage, perforations and fistulas.METHODS: From 02-2009 to 10-2012, 84...AIM: To investigate the efficacy and clinical outcome of patients treated with an over-the-scope-clip(OTSC) system for severe gastrointestinal hemorrhage, perforations and fistulas.METHODS: From 02-2009 to 10-2012, 84 patients were treated with 101 OTSC clips. 41 patients(48.8%) presented with severe upper-gastrointestinal(GI) bleeding, 3(3.6%) patients with lower-GI bleeding, 7 patients(8.3%) underwent perforation closure, 18 patients(21.4%) had prevention of secondary perforation, 12 patients(14.3%) had control of secondary bleeding after endoscopic mucosal resection or endoscopic submucosal dissection(ESD) and 3 patients(3.6%) had an intervention on a chronic fistula. RESULTS: In 78/84 patients(92.8%), primary treatment with the OTSC was technically successful. Clinical primary success was achieved in 75/84 patients(89.28%). The overall mortality in the study patients was 11/84(13.1%) and was seen in patients with life threatning upper GI hemorrhage. There was no mortality in any other treatment group. In detail OTSC application lead to a clinical success in 35/41(85.36%) patients with upper GI bleeding and in 3/3 patients with lower GI bleeding. Technical success of perforation closure was 100% while clinical success was seen in 4/7 cases(57.14%) due to attendant circumstances unrelated to the OTSC. Technical and clinic success was achieved in 18/18(100%) patients for the prevention of bleeding or perforation after endoscopic mucosal resection and ESD and in 3/3 cases of fistula closure. Two application-related complications were seen(2%).CONCLUSION: This largest single center experience published so far confirms the value of the OTSC for GI emergencies and complications. Further clinical experience will help to identify optimal indications for its targeted and prophylactic use.展开更多
Bleeding of peptic ulcer at the posterior duodenal bulb still is a particular endoscopic challenge with increased risk of treatment failure and worse outcome.In this article,we report successful treatment of an active...Bleeding of peptic ulcer at the posterior duodenal bulb still is a particular endoscopic challenge with increased risk of treatment failure and worse outcome.In this article,we report successful treatment of an actively bleeding peptic ulcer located at the posterior duodenal wall,using an over-the-scope-clip in the case of a 54-year-old male patient with hemorrhagic shock.Incident primary hemostasis was achieved and no adverse events occurred during a follow-up of 60 d.展开更多
Rectal perforations due to glycerin enemas(GE) typically occur when the patient is in a seated or lordotic standing position.Once the perforation occurs and peritonitis results,death is usually inevitable.We describe ...Rectal perforations due to glycerin enemas(GE) typically occur when the patient is in a seated or lordotic standing position.Once the perforation occurs and peritonitis results,death is usually inevitable.We describe two cases of rectal perforation and fistula caused by a GE.An 88-year-old woman presented with a large rectal perforation and a fistula just after receiving a GE.Her case was further complicated by an abscess in the right rectal wall.The second patient was a 78-year-old woman who suffered from a rectovesical fistula after a GE.In both cases,we performed direct endoscopic abscess lavage with a saline solution and closed the fistula using an over-the-scope-clip(OTSC) procedure.These procedures resulted in dramatic improvement in both patients.Direct endoscopic lavage and OTSC closure are very useful for pararectal abscess lavage and fistula closure,respectively,in elderly patients who are in poor general condition.Our two cases are the first reports of the successful endoscopic closure of fistulae using double OTSCs after endoscopic lavage of the debris and an abscess of the rectum secondary to a GE.展开更多
Percutaneous endoscopic gastrostomy(PEG) is a common practice for long-term nutrition of patients who are unable to take oral food. We report of an 85-year old man with a history of recurrent larynx carcinoma and hemi...Percutaneous endoscopic gastrostomy(PEG) is a common practice for long-term nutrition of patients who are unable to take oral food. We report of an 85-year old man with a history of recurrent larynx carcinoma and hemicolectomy many years ago due to unknown reason. Laryngectomy was indicated. Preoperatively a PEG was inserted endoscopically after an abdominal ultrasonography without abnormal findings. Few months after PEG insertion, the patient was evaluated for diarrhea and insufficient feeding without signs of infection or peritonism. An upper endoscopy and computed tomography scan confirmed a buried bumper syndrome with migration of the PEG tube into the colon as a rare complication. He underwent successful colonoscopic removal of the internal bumper and closure of the colonic orifice of the fistula with the over-the-scope-clip system(OTSC). OTSC is an endoscopic device for treatment of bleeding, perforation, leak and fistula in the gastrointestinal tract. To the best of our knowledge, this is the first report of the use of OTSC for colonoscopic closure of a gastrocolocutaneous fistula due to a buried bumper syndrome with transcolonic PEG tube migration.展开更多
AIM:To evaluate the outcome of over-the-scope-clip system(OTSC)for endoscopic treatment of various indications in daily clinical practice in Switzerland.METHODS:This prospective,consecutive case series was conducted a...AIM:To evaluate the outcome of over-the-scope-clip system(OTSC)for endoscopic treatment of various indications in daily clinical practice in Switzerland.METHODS:This prospective,consecutive case series was conducted at a tertiary care hospital from September 2010 to January 2014.Indications for OTSC application were fistulae,anastomotic leakage,perforation,unroofed submucosal lesion for biopsy,refractory bleeding,and stent fixation in the gastrointestinal(GI)tract.Primary technical success was defined as the adequate deployment of the OTSC on the target lesion.Clinical success was defined as resolution of the problem;for instance,no requirement for surgery or further endoscopic intervention.In cases of recurrence,retreatment of a lesion with a second intervention was possible.Complications were classified into those related to sedation,endoscopy,or deployment of the clip.RESULTS:A total of 28 OTSC system applications werecarried out in 21 patients[median age 64 years(range42-85),33%females].The main indications were fistulae(52%),mostly after percutaneous endoscopic gastrostomy tube removal,and anastomotic leakage after GI surgery(29%).Further indications were unroofed submucosal lesions after biopsy,upper gastrointestinal bleeding,or esophageal stent fixation.The OTSC treatments were applied either in the upper(48%)or lower(52%)GI tract.The mean lesion size was 8 mm(range:2-20 mm).Primary technical success and clinical success rates were 85%and 67%,respectively.In53%of cases,the suction method was used without accessories(e.g.,twin grasper or tissue anchor).No endoscopy-related or OTSC-related complications were observed.CONCLUSION:OTSC is a useful tool for endoscopic closure of various GI lesions,including fistulae and leakages.Future randomized prospective multicenter trials are warranted.展开更多
Peak load and wind energy emission pressure rise more as wind energy penetration keeps growing,which affects the stabilization of the PS(power system).This paper suggests integrated optimal dispatching of thermal powe...Peak load and wind energy emission pressure rise more as wind energy penetration keeps growing,which affects the stabilization of the PS(power system).This paper suggests integrated optimal dispatching of thermal power generators and BESS(battery energy storage system)taking wind energy emission grading punishment and deep peak clipping into consideration.Firstly,in order to minimize wind abandonment,a hierarchical wind abandonment penalty strategy based on fuzzy control is designed and introduced,and the optimal grid-connected power of wind energy is determined as a result of minimizing the peak cutting cost of the system.Secondly,considering BESS and thermal power,the management approach of BESS-assisted virtual peak clipping of thermal power generators is aimed at reducing the degree of deep peak clipping of thermal power generators and optimizing the output of thermal power generators and the charging and discharging power of BESS.Finally,Give an example of how this strategy has been effective in reducing abandonment rates by 0.66% and 7.46% individually for different wind penetration programs,and the daily average can reduce the peak clipping power output of thermal power generators by 42.97 and 72.31 MWh and enhances the effect and economy of system peak clipping.展开更多
文摘BACKGROUND The over-the-scope clip(OTSC)system has been increasingly utilized as a nonsurgical option to endoscopically manage refractory gastrointestinal(GI)hemorrhage,perforations/luminal defects and fistulas.Limited data exist evaluating the efficacy and safety of OTSC.AIM To determine the clinical success and adverse event(AE)rates of OTSC across all GI indications.METHODS A PubMed search was conducted for eligible articles describing the application of the OTSC system for any indication in the GI tract.Any article or case series reporting data for less than 5 total patients was excluded.The primary outcome was the rate of clinical success.Secondary outcomes included:Technical success rate,OTSC-related AE rate and requirement for surgical intervention despite-OTSC placement.Pooled rates(per-indication and overall)were calculated as the number of patients with the event of interest divided by the total number of patients.RESULTS A total of 85 articles met our inclusion criteria(n=3025 patients).OTSC was successfully deployed in 94.4%of patients(n=2856/3025).The overall rate of clinical success(all indications)was 78.4%(n=2371/3025).Per-indication clinical success rates were as follows:(1)86.0%(1120/1303)for GI hemorrhage;(2)85.3%(399/468)for perforation;(3)55.8%(347/622)for fistulae;(4)72.6%(284/391)for anastomotic leaks;(5)92.8%(205/221)for defect closure following endoscopic resection(e.g.,following endoscopic mucosal resection or endoscopic submucosal dissection);and(6)80.0%(16/20)for stent fixation.AE’s related to the deployment of OTSC were only reported in 64 of 85 studies(n=1942 patients),with an overall AE rate of 2.1%(n=40/1942).Salvage surgical intervention was required in 4.7%of patients(n=143/3025).CONCLUSION This systematic review demonstrates that the OTSC system is a safe and effective endoscopic therapy to manage GI hemorrhage,perforations,anastomotic leaks,defects created by endoscopic resections and for stent fixation.Clinical success in fistula management appears limited.Further studies,including randomized controlled trials comparing OTSC with conventional and/or surgical therapies,are needed to determine which indication(s)are the most effective for its use.
基金Supported by Program of Taizhou Science and Technology Grant,No.20ywb29Medical Health Science and Technology Project of Zhejiang Province,No.2021PY083 and No.2019KY239+2 种基金Key Technology Research and Development Program of Zhejiang Province,No.2019C03040Major Research Program of Taizhou Enze Medical Center Grant,No.19EZZDA2Open Fund of Key Laboratory of Key Laboratory of Minimally Invasive Techniques&Rapid Rehabilitation of Digestive System Tumor of Zhejiang Province,No.21SZDSYS01 and No.21SZDSYS09。
文摘BACKGROUND Endoscopic resection of duodenal subepithelial lesions(SELs)is a difficult procedure with a high risk of perforation.At present,dealing with perforation after endoscopic resection of duodenal SELs is still considered a great challenge.AIM To evaluate the effectiveness and safety of an over-the-scope clip(OTSC)in the treatment of perforation post-endoscopic resection of duodenal SELs.METHODS From May 2015 to November 2019,18 patients with perforation following endoscopic resection of duodenal SELs were treated with OTSCs.Data comprising the rate of complete resection,closure of intraprocedural perforation,delayed bleeding,delayed perforation,and postoperative infection were extracted.RESULTS The rate of complete removal of duodenal SELs and successful closure of the perforation was 100%.The median perforation size was 1 cm in diameter.Seventeen patients had minor intraoperative bleeding,while the remaining 1 patient had considerable amount of bleeding during the procedure.Seven patients had postoperative abdominal infections,of which 1 patient developed an abscess in the right iliac fossa and another patient developed septic shock.All 18 patients recovered and were discharged.No delayed bleeding or perforation was reported.The mean time taken to resume normal diet after the procedure was 6.5 d.The mean postoperative hospital stay was 9.5 d.No residual or recurrent lesions were detected during the follow-up period(15-66 mo).CONCLUSION Closing a perforation after endoscopic resection of duodenal SELs with OTSCs seems to be an effective and reasonably safe therapeutic method.
文摘AIM: To retrospectively review the results of over-thescope clip (OTSC) use in our hospital and to examine the feasibility of using the OTSC to treat perforations after endoscopic submucosal dissection (ESD). METHODS: We enrolled 23 patients who presented with gastrointestinal (GI) bleeding, fistulae and perforations and were treated with OTSCs (Ovesco Endoscopy GmbH, Tuebingen, Germany) between November 2011 and September 2012. Maximum lesion size was defined as lesion diameter. The number of OTSCs to be used per patient was not decided until the lesion was completely closed. We used a twin grasper (Ovesco Endoscopy GmbH, Tuebingen, Germany) as a grasping device for all the patients. A 9 mm OTSC was chosen for use in the esophagus and colon, and a 10 mm device was used for the stomach, duodenum and rectum. The overall success rate and complications were evaluated, with a particular emphasis on patients who had undergone ESD due to adenocarcinoma. In technical successful cases we included not only complete closing by using OTSCs, but also partial closing where complete closure with OTSCs is almost difficult. In overall clinical successful cases we included only complete closing by using only OTSCs perfectly. All the OTSCs were placed by 2 experienced endoscopists. The sites closed after ESD included not only the perforation site but also all defective ulcers sites.RESULTS: A total of 23 patients [mean age 77 years (range 64-98 years)] underwent OTSC placement during the study period. The indications for OTSC placement were GI bleeding (n = 9), perforation (n = 10), fistula (n = 4) and the prevention of post-ESD duodenal artificial ulcer perforation (n = 1). One patient had a perforation caused by a glycerin enema, after which a fistula formed. Lesion closure using the OTSC alone was successful in 19 out of 23 patients, and overall success rate was 82.6%. A large lesion size (greater than 20 mm) and a delayed diagnosis (more than 1 wk) were the major contributing factors for the overall unsuccessful clinical cases. The location of the unsuccessful lesion was in the stomach. The median operation time in the successful cases was 18 min, and the average observation time was 67 d. During the observation period, none of the patients experienced any complications associated with OTSC placement. In addition, we successfully used the OTSC to close the perforation site after ESD in 6 patients. This was a single-center, retrospective study with a small sample size. CONCLUSION: The OTSC is effective for treating GI bleeding, fistulae as well as perforations, and the OTSC technique proofed effective treatment for perforation after ESD.
文摘AIM: To determine the outcome of the management of iatrogenic gastrointestinal tract perforations treated by over-the-scope clip(OTSC) placement.METHODS: We retrospectively enrolled 20 patients(13 female and 7 male; mean age: 70.6 ± 9.8 years) in eight high-volume tertiary referral centers with upper or lower iatrogenic gastrointestinal tract perforation treated by OTSC placement. Gastrointestinal tract perforation could be with oval-shape or with round-shape. Ovalshape perforations were closed by OTSC only by suction and the round-shape by the "twin-grasper" plus suction. RESULTS: Main perforation diameter was 10.1 ± 4.3 mm(range 3-18 mm). The technical success rate was 100%(20/20 patients) and the clinical success rate was 90%(18/20 patients). Two patients(10%) who did not have complete sealing of the defect underwent surgery. Based upon our observations we propose two types of perforation: Round-shape "type-1 perforation" and oval-shape "type-2 perforation". Eight(40%) out of the 20 patients had a type-1 perforation and 12 patients a type-2(60%). CONCLUSION: OTSC placement should be attempted after perforation occurring during diagnostic or therapeutic endoscopy. A failed closure attempt does not impair subsequent surgical treatment.
文摘AIM To evaluate rebleeding, primary failure(PF) and mortality of patients in whom over-the-scope clips(OTSCs) were used as first-line and second-line endoscopic treatment(FLET, SLET) of upper and lower gastrointestinal bleeding(UGIB, LGIB).METHODS A retrospective analysis of a prospectively collected database identified all patients with UGIB and LGIB in a tertiary endoscopic referral center of the University of Freiburg, Germany, from 04-2012 to 05-2016(n= 93) who underwent FLET and SLET with OTSCs. The complete Rockall risk scores were calculated from patients with UGIB. The scores were categorized as < or ≥ 7 and were compared with the original Rockall data. Differences between FLET and SLET were calculated. Univariate and multivariate analysis were performed to evaluate the factors that influenced rebleeding after OTSC placement.RESULTS Primary hemostasis and clinical success of bleeding lesions(without rebleeding) was achieved in 88/100(88%) and 78/100(78%), respectively. PF was significantly lower when OTSCs were applied as FLET compared to SLET(4.9% vs 23%, P = 0.008). In multivariate analysis, patients who had OTSC placement as SLET had a significantly higher rebleeding risk compared to those who had FLET(OR 5.3; P = 0.008). Patients with Rockall risk scores ≥ 7 had a significantly higher in-hospital mortality compared to those with scores < 7(35% vs 10%, P = 0.034). No significant differences were observed in patients with scores < or ≥ 7 in rebleeding and rebleeding-associated mortality.CONCLUSION Our data show for the first time that FLET with OTSC might be the best predictor to successfully prevent rebleeding of gastrointestinal bleeding compared to SLET. The type of treatment determines the success of primary hemostasis or primary failure.
文摘This paper reports our experience with a new overthe-scope clip in the setting of recurrent bleeding and oesophageal fistula. We treated five patients with the over-the-scope Padlock Clip?. It is a nitinol ring, with six inner needles preassembled on an applicator cap, thumb press displaced by the Lock-It? delivery system. The trigger wire is located alongside the shaft of the endoscope, and does not require the working channel. Three patients had recurrent bleeding lesions(bleeding rectal ulcer, post polypectomy delayed bleeding and duodenal Dieulafoy's lesion) and two patients had a persistent respiratory-esophageal fistula. In all patients a previous endoscopic attempt with standard techniques had been useless. All procedures were conducted under conscious sedation but for one patient that required general anaesthesia due to multiple comorbidities. We used one Padlock Clip? for each patient in a single session. Simple suction was enough in all of our patients to obtain tissue adhesion to the instrument tip. A remarkably short application time was recorded for all cases(mean duration of the procedure: 8 min). We obtained technical and immediate clinical success for every patient. No major immediate, early or late(within 24 h, 7 d or 4 wk) adverse events were observed, over follow-up durations lasting a mean of 109.4 d. One patient, treated for duodenal bulb bleeding from a Dieulafoy's lesion, developed signs of mild pancreatitis 24 h after the procedure. The new over-the-scope Padlock Clip? seems to be simple to use and effective in different clinical settings, particularly in "difficult" scenarios, like recurrent bleeding and respiratory-oesophageal fistulas.
文摘An ileal pouch fistula is an uncommon complication after an ileal pouch anal anastomosis. Most patients who suffer from an ileal pouch fistula will need surgical intervention. However, the surgery can be invasive and has a high risk compared to endoscopic treatment. The over-the-scope clip(OTSC) system was initially developed for hemostasis and leakage closure in the gastrointestinal tract during flexible endoscopy. There have been many successes in using this approach to apply perforations to the upper gastrointestinal tract. However, this approach has not been used for ileal pouch fistulas until currently. In this report, we describe one patient who suffered a leak from the tip of the "J" pouch and was successfully treated with endoscopic closure via the OTSC system. A 26-year-old male patient had an intestinal fistula at the tip of the "J" pouch after an ileal pouch anal anastomosis procedure. He received endoscopic treatment via OTSC under intravenous anesthesia, and the leak was closed successfully. Endoscopic closure of a pouch fistula could be a simpler alternative to surgery and could help avoid surgeryrelated complications.
文摘Endoscopic management of leakages and perforations of the upper gastrointestinal tract has gained great importance as it avoids the morbidity and mortality of surgical intervention.In the past years,covered selfexpanding metal stents were the mainstay of endoscopic therapy.However,two new techniques are now available that enlarge the possibilities of defect closure:endoscopic vacuum therapy(EVT),and over-the-scope clip(OTSC).EVT is performed by mounting a polyurethane sponge on a gastric tube and placing it into the leakage.Continuous suction is applied via the tube resulting in effective drainage of the cavity and the induction of wound healing,comparable to the application of vacuum therapy in cutaneous wounds.The system is changed every 3-5 d.The overall success rate of EVT in the literature ranges from 84%to 100%,with a mean of 90%;only few complications have been reported.OTSCs are loaded on a transparent cap which is mounted on the tip of a standard endoscope.By bringing the edges of the perforation into the cap,by suction or by dedicated devices,such as anchor or twin grasper,the OTSC can be placed to close the perforation.For acute endoscopy associated perforations,the mean success rate is 90%(range:70%-100%).For other types of perforations(postoperative,other chronic leaks and fistulas)success rates are somewhat lower(68%,and59%,respectively).Only few complications have been reported.Although first reports are promising,further studies are needed to define the exact role of EVT and OTSC in treatment algorithms of upper gastrointestinal perforations.
基金Supported by National Natural Science Foundation of ChinaNo.81201908
文摘Over-the-scope clip(OTSC) system is becoming a new reliable technique which is available for the endoscopic closure of fistulas, bleeding, perforations and so on. We describe the case of a patient with a nonhealing gastrocutaneous fistula after esophagectomy for esophageal squamous cell carcinoma which was successfully closed using an OTSC system. This is the first report of the use of OTSC to treat a nonhealing gastrocutaneous fistula successfully after esophagectomy. We believe our experience will give such patients an ideal way to cure the fistula without suffering too much and also explore new application of OTSC.
文摘Gastrointestinal (GI) defects such as fistulas and leaks can be potentially closed endoscopically using hemo-clips and loops. However, hemoclips may not allow for closure of large defects and they do not exert enough tensile force to keep fibrotic defects larger than 5 mm approximated. Herein we present a case of successful endoscopic closure of a gastrocolic fistula in a severely malnourished patient with complex post-surgical upper GI anatomy. We strongly believe that this device is a major breakthrough for the management of various types of discontinuity defects or fistulas. In addition, we show the usefulness of placing a direct jejunostomy using the double balloon enteroscopy (DBE) technique during the same procedure. The concept of providing direct jejunal feedings while allowing for upper gas-trointestinal bowel rest to promote the healing of the minimally invasive endoscopic operation is novel. Thus, our case is unique and exemplifies the utility of mini-mally invasive endoscopic endoluminal surgery.
基金Supported by The“Endo-Verein Erlangen”a registered non-profit training organization+1 种基金BaiersdorfGermany
文摘AIM: To investigate the efficacy and clinical outcome of patients treated with an over-the-scope-clip(OTSC) system for severe gastrointestinal hemorrhage, perforations and fistulas.METHODS: From 02-2009 to 10-2012, 84 patients were treated with 101 OTSC clips. 41 patients(48.8%) presented with severe upper-gastrointestinal(GI) bleeding, 3(3.6%) patients with lower-GI bleeding, 7 patients(8.3%) underwent perforation closure, 18 patients(21.4%) had prevention of secondary perforation, 12 patients(14.3%) had control of secondary bleeding after endoscopic mucosal resection or endoscopic submucosal dissection(ESD) and 3 patients(3.6%) had an intervention on a chronic fistula. RESULTS: In 78/84 patients(92.8%), primary treatment with the OTSC was technically successful. Clinical primary success was achieved in 75/84 patients(89.28%). The overall mortality in the study patients was 11/84(13.1%) and was seen in patients with life threatning upper GI hemorrhage. There was no mortality in any other treatment group. In detail OTSC application lead to a clinical success in 35/41(85.36%) patients with upper GI bleeding and in 3/3 patients with lower GI bleeding. Technical success of perforation closure was 100% while clinical success was seen in 4/7 cases(57.14%) due to attendant circumstances unrelated to the OTSC. Technical and clinic success was achieved in 18/18(100%) patients for the prevention of bleeding or perforation after endoscopic mucosal resection and ESD and in 3/3 cases of fistula closure. Two application-related complications were seen(2%).CONCLUSION: This largest single center experience published so far confirms the value of the OTSC for GI emergencies and complications. Further clinical experience will help to identify optimal indications for its targeted and prophylactic use.
文摘Bleeding of peptic ulcer at the posterior duodenal bulb still is a particular endoscopic challenge with increased risk of treatment failure and worse outcome.In this article,we report successful treatment of an actively bleeding peptic ulcer located at the posterior duodenal wall,using an over-the-scope-clip in the case of a 54-year-old male patient with hemorrhagic shock.Incident primary hemostasis was achieved and no adverse events occurred during a follow-up of 60 d.
文摘Rectal perforations due to glycerin enemas(GE) typically occur when the patient is in a seated or lordotic standing position.Once the perforation occurs and peritonitis results,death is usually inevitable.We describe two cases of rectal perforation and fistula caused by a GE.An 88-year-old woman presented with a large rectal perforation and a fistula just after receiving a GE.Her case was further complicated by an abscess in the right rectal wall.The second patient was a 78-year-old woman who suffered from a rectovesical fistula after a GE.In both cases,we performed direct endoscopic abscess lavage with a saline solution and closed the fistula using an over-the-scope-clip(OTSC) procedure.These procedures resulted in dramatic improvement in both patients.Direct endoscopic lavage and OTSC closure are very useful for pararectal abscess lavage and fistula closure,respectively,in elderly patients who are in poor general condition.Our two cases are the first reports of the successful endoscopic closure of fistulae using double OTSCs after endoscopic lavage of the debris and an abscess of the rectum secondary to a GE.
文摘Percutaneous endoscopic gastrostomy(PEG) is a common practice for long-term nutrition of patients who are unable to take oral food. We report of an 85-year old man with a history of recurrent larynx carcinoma and hemicolectomy many years ago due to unknown reason. Laryngectomy was indicated. Preoperatively a PEG was inserted endoscopically after an abdominal ultrasonography without abnormal findings. Few months after PEG insertion, the patient was evaluated for diarrhea and insufficient feeding without signs of infection or peritonism. An upper endoscopy and computed tomography scan confirmed a buried bumper syndrome with migration of the PEG tube into the colon as a rare complication. He underwent successful colonoscopic removal of the internal bumper and closure of the colonic orifice of the fistula with the over-the-scope-clip system(OTSC). OTSC is an endoscopic device for treatment of bleeding, perforation, leak and fistula in the gastrointestinal tract. To the best of our knowledge, this is the first report of the use of OTSC for colonoscopic closure of a gastrocolocutaneous fistula due to a buried bumper syndrome with transcolonic PEG tube migration.
文摘AIM:To evaluate the outcome of over-the-scope-clip system(OTSC)for endoscopic treatment of various indications in daily clinical practice in Switzerland.METHODS:This prospective,consecutive case series was conducted at a tertiary care hospital from September 2010 to January 2014.Indications for OTSC application were fistulae,anastomotic leakage,perforation,unroofed submucosal lesion for biopsy,refractory bleeding,and stent fixation in the gastrointestinal(GI)tract.Primary technical success was defined as the adequate deployment of the OTSC on the target lesion.Clinical success was defined as resolution of the problem;for instance,no requirement for surgery or further endoscopic intervention.In cases of recurrence,retreatment of a lesion with a second intervention was possible.Complications were classified into those related to sedation,endoscopy,or deployment of the clip.RESULTS:A total of 28 OTSC system applications werecarried out in 21 patients[median age 64 years(range42-85),33%females].The main indications were fistulae(52%),mostly after percutaneous endoscopic gastrostomy tube removal,and anastomotic leakage after GI surgery(29%).Further indications were unroofed submucosal lesions after biopsy,upper gastrointestinal bleeding,or esophageal stent fixation.The OTSC treatments were applied either in the upper(48%)or lower(52%)GI tract.The mean lesion size was 8 mm(range:2-20 mm).Primary technical success and clinical success rates were 85%and 67%,respectively.In53%of cases,the suction method was used without accessories(e.g.,twin grasper or tissue anchor).No endoscopy-related or OTSC-related complications were observed.CONCLUSION:OTSC is a useful tool for endoscopic closure of various GI lesions,including fistulae and leakages.Future randomized prospective multicenter trials are warranted.
基金supported by Jilin Province Higher Education Teaching Reform Research Project in 2021(JLJY202186163419).
文摘Peak load and wind energy emission pressure rise more as wind energy penetration keeps growing,which affects the stabilization of the PS(power system).This paper suggests integrated optimal dispatching of thermal power generators and BESS(battery energy storage system)taking wind energy emission grading punishment and deep peak clipping into consideration.Firstly,in order to minimize wind abandonment,a hierarchical wind abandonment penalty strategy based on fuzzy control is designed and introduced,and the optimal grid-connected power of wind energy is determined as a result of minimizing the peak cutting cost of the system.Secondly,considering BESS and thermal power,the management approach of BESS-assisted virtual peak clipping of thermal power generators is aimed at reducing the degree of deep peak clipping of thermal power generators and optimizing the output of thermal power generators and the charging and discharging power of BESS.Finally,Give an example of how this strategy has been effective in reducing abandonment rates by 0.66% and 7.46% individually for different wind penetration programs,and the daily average can reduce the peak clipping power output of thermal power generators by 42.97 and 72.31 MWh and enhances the effect and economy of system peak clipping.