Endoscopic closure of iatrogenic perforation
Phonthep Angsuwatcharakon, Rungsun Rerknimitr
Abstract
Iatrogenic perforation of the gastrointestinal (GI) tract is one of the serious complications in GI endoscopy. With the advancement in technique of GI endoscopy especially therapeutic endoscopy, the risk of perforation has increased. Prompt detection is the only way to avoid delay treatment and poor outcome. Recently, there are new instruments and techniques developed that can be reliably applied for an endoscopic closure without the need for surgery. Therefore, endoscopists should be familiar with these instruments as the result of successful endoscopic closure has lower rate of morbidity than surgery. In this review, the techniques of endoscopic closure are described according to the organs of perforation. In addition, the general knowledge and management of perforation in other aspects including tension pneumothorax, abdominal compartment syndrome, or infection induced by contamination of GI content are explained.
Introduction
Gastrointestinal (GI) endoscopy provides both diagnosis and treatment of various GI disorders through the natural lumens. Many of therapeutic endoscopic procedures such as polypectomy, sphincterotomy, dilation, endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), peroral endoscopic myotomy, etc. require dissection or cutting the mucosal and submucosal layers of the GI tract, in a very rare occasion, an inadvertent full thickness injury so called “perforation” could develop. Traditionally, surgery is the only rescue treatment for this iatrogenic perforation.1–3 Recently, with the application of many endoscopic gadgets such as stent, band, endoclip, an endoscopic closure could be employed as the primary treatment for perforation4 and this in turn may result to the lower rate of morbidity than the previous surgical approach.5
Incidence of Perforation
Iatrogenic esophageal perforation is a mishap associated with many diagnostic and therapeutic interventions of the esophagus,6–9 such as an insertion of duodenoscope10/echoendoscope11/transesophageal echocardiogram transducer12/esophageal dilator13 and Sengstaken Blakemore tube misplacement.14 The incidences of perforation ranged from 0.09% to 4.1% depending on the types of procedure (Table 1). The reported overall immediate mortality rate of iatrogenic esophageal perforation was as high as 13.2%.5 Perforation in different esophageal locations had different rate of mortality. For instance, cervical esophageal perforation had the lowest mortality rate at 0% to 5.9%, followed by 10.9% to 16.7% in thoracic esophageal perforation, whereas abdominal esophageal perforation had the highest mortality at 13.2% to 16.7%.5,15 The other factor that influenced the mortality rate was timing of detection, the mortality rate was reported to be at 3.0% to 7.4% when perforation diagnosed within 24 hours whereas the mortality rate would be as high as 20.3% to 36.4% when the diagnosis was made after 24 hours.5,15
Gastric perforation is reportedly rare during esophagogastroduodenoscopy with the incidence of 0.001%.16 The risk of perforation increased in therapeutic procedure of the stomach such as EMR (0%–5.3%) or ESD (0%–6.4%).17,18 ESD of the proximal part19 or the greater curvature20 of stomach portends a higher risk of perforation with the odds ratio (95% confidence interval) of 4.88 (2.21–10.75) and 7.0 (3.1–15.8), respectively. In certain procedures, such as natural orifice transluminal endoscopic surgery and endoscopic full thickness resection (EFTR), the gastric wall is intentionally penetrated as a full thickness perforation, these procedures thereby need a complete closure.21,22
Duodenal perforation developed in 0.2% to 1% during endoscopic retrograde cholangiopancreatography (ERCP),23,24 0.022% during diagnostic endoscopic ultrasonography (EUS), and 0.09% during EUS-fine needle aspiration.25 Stapfer et al26 proposed the classification of ERCP-related perforation as type 1: injury of lateral duodenal wall, type 2: injury at sphincter of Oddi, type 3: ductal injury, and type 4: retroperitoneal air alone. The proportion of ERCP-related perforation in each type were 34.5% in type 1, 31.3% in type 2, 23% in type 3, and 0.8% in type 4.23 Stapfer type 1 (caused by an endoscope) and some of Stapfer type 2 (caused by sphincterotomy) were recommended to be treated by immediate surgery while in types 3–4 or in selected type 2 patients can be treated by non-operative measure.26,27 The surgically altered anatomy, e.g., previous Billroth II anastomosis, may increase the risk for Stapfer type 1 perforation28 which is explained by alteration of gut direction, acute angulation of lumen, and adhesion from previous surgery. Risk factors for Stapfer type 2 or 3 perforations were sphincterotomy, sphincter of Oddi dysfunction, dilated common bile duct, and biliary stricture dilation.29 The overall mortality of ERCP-related perforation was reported at 8.0% to 9.9%.23,24
Colonic perforation occurred about 0.01% to 0.10% during both diagnostic and therapeutic colonoscopies.30 Diagnostic colonoscopy had lower rate of perforation than colonoscopy with polypectomy (0.01% vs 0.1%)30,31 and sigmoid colon was reported as the most common location for perforation.31 Other factors that associated with perforation are polyp larger than 1 cm, numbers of polyp > 4, emergency colonoscopy, low volume colonoscopist,30 or polyp at the cecum.32 Colonic perforation during diagnostic colonoscopy is mostly caused by the scope and this injury seems to have a large colonic wall defect (mean size 19.3 mm). It cannot be treated conservatively.31,33 Contrastly therapeutic polypectomy induced perforation has a smaller defect (mean size 5.8 mm), and most patients can be treated conservatively.31,33 In addition, EMR related perforation can be immediately recognized if there is a “target sign” (Fig. 1) indicating muscularis propria injury in the resected specimen.34
Management
General management
Early detection of perforation is crucial as the first step of management. Visualization of mediastinal organs (thoracic esophageal perforation), or intra-abdominal organs or omentum or retroperitoneum (abdominal esophageal, gastric, duodenal or colonic perforation) is evidenced for the diagnosis of perforation. While using a side-viewing duodenoscope, perforation may not be directly visualized by the scope. Therefore, endoscopists should be aware of other indirect signs such as patients’ discomfort, change in vital sings, cutaneous emphysema, and observation of pneumoperitoneum/pneumoretroperitoneum under fluoroscopy (Fig. 2). When perforation is detected the endoscopists should not be panic. Instead he or she should promptly evaluate the perforation in term of size, shape, and location. Air insufflation should be switched to CO2, if available. Intraluminal content should be cleaned out to prevent extra-luminal contamination, or patients’ position should be adjusted to shift the luminal fluid away from the perforation site. Patients’ vital signs should be closely monitored. If hemodynamic status of the patient is unstable, tension pneumothorax or abdominal compartment syndrome should be investigated and immediate air release should be instantaneously performed without delay. An intravenous broad spectrum antibiotic covering for enterobacteriaceae and anaerobic bacteria should be administered. After the procedure, patients should be kept fasting until mucosal healing is achieved. Nasogastric tube may be inserted for enteral nutrition in the case with esophageal perforation, or for GI luminal decompression in others. Before resuming an oral intake, water soluble contrast leakage test should be performed to confirm the complete closure of the defect.
Endoscopic management
Endoscopic band ligation (EBL) is usually used for esophageal variceal ligation. There was a study using EBL for a closure of perforation in porcine model. The appropriate size of esophageal perforation that EBL could be successfully performed had to be equal or smaller than 10 mm whereas EBL failed to close the perforation size that larger than 15 mm.54
The endoscopic suturing devices, e.g., OverStitch, Eagle Claw, or successive suturing devices, have been recently developed. These instruments provided effective closure of gastric perforation ex vivo,73,74 and in vivo of animal models.75 The success rate of closure ranged from 87.5% to 100%.76 In human, OverStitch has been reported in a retrospective study of 15 patients with iatrogenic perforation. The locations located in esophagus in 13 patients, duodenum in 1 patient, and colon in 1 patient. The mean defect sizes were 30 mm (range, 25–50 mm). The success rate of OverStitch for closure of perforation was 93.3%.77
Although most of sphincterotomy-related perforation can be treated conservatively, a closure should be carried out when large perforation is detected to prevent major spillage of GI content. TTS clip has been reported to achieve successful closure in this type of perforation.87–89 According to the location that is difficult to approach by the forward-viewing scope, the side-viewing scope could be used for a closure. The drawback of using the side-viewing scope is that the endoclipping device can become kinking and malfunctioning because of the tension made by the elevator of the side-viewing scope.87,89 FCSEMS has been reported for the treatment of Stapfer type 2 perforations in 6 patients, the duration of stent placement was 10 to 30 day, with 100% success rate. Spontaneous stent migration occurred in one after the complete closure of perforation.90
OTSC also has compression force comparable to hand suture in ex vivo porcine model.91 In a prospective study included 12 colon perforations, OTSC showed technical success rate of 100%, and clinical success rate of 92%. One patient developed OTSC detachment at 5 hours after the procedure which caused persistent perforation.53
Conclusion
The incidence of iatrogenic GI perforation has increased especially in the era of advanced therapeutic procedures. Surgery is still the standard treatment for perforation. However, endoscopic closure can be attempted in certain situations. Each location and size needs different therapeutic techniques (Table 2). TTS clip can be used to close the perforation in esophagus, stomach, duodenum, and colon. The main limitation of application of TTS clip is the width of the defect should be less than the span of the clip. EBL or endoloop can be used in conjunction with TTS clip in a larger perforation. OTSC can be applied at all anatomical location similar to TTS clip except Stapfer type 2 duodenal perforation near the ampulla, and the size of perforation that can be closed by OTSC is up to 30 mm. FCSEMS can be used in esophagus or Stapfer type 2 duodenal perforation because of straight tubular structure of esophagus and bile duct. In esophageal perforation FCSEMS can cover the larger area of perforation. However, FC-SEMS migration could develop in non-stricture related perforation, thereby anchoring technique is helpful. After closure patients should be closely monitored, when clinical deterioration detected, surgery will be the definite treatment. Nevertheless, endoscopic suture device is still in its developmental phase and the technique has to be refined for more reliable use.
Acknowledgments
Authors would like to thank Assoc. Prof. Rajvinder Singh, MBBS, MRCP, MPhil, FRACP, AM FRCP, Director, Consultant Gastroenterologist, Clinical Associate Professor, The Lyell McEwin Hospital & University of Adelaide, Endoscopy Unit, Haydown Road, Elizabeth Vale 5112 SA, Australia for providing Fig. 1 and 4.
Article information
Articles from Gastrointestinal Intervention are provided here courtesy of Gastrointestinal Intervention
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