Abstract
Background:
Perforation can occur in the midst of a diagnostic or therapeutic procedure. 1 –3 Urgent surgical repair has been the most common response to treat iatrogenic perforation during endoscopy. As more endoscopic procedures develop, the risk of endoscopic perforations has increased, but so has our experience in managing them endoscopically. 4 The purpose of this video is to demonstrate the adaptability and effectiveness of endoscopic suturing in the treatment of a wide range of complicated iatrogenic perforations along the upper gastrointestinal tract.
Materials/Methods:
Three patients undergoing different endoscopic procedures were complicated by acute perforation. We present this series of cases to highlight the utility and efficacy of managing patients with acute iatrogenic perforations using endoscopic suturing.
Results:
Case 1: An 85-year-old woman began to experience jaundice and weight loss. A 2.8 cm mass was found in the head of the pancreas on a CT scan. During an endoscopic ultrasound (EUS), the patient suffered an iatrogenic perforation of the duodenal bulb. Upon entry into the duodenum, gross contamination and a 9 mm defect were seen. Owing to difficulty in maintaining pneumogastrium, a Veress needle was placed in the umbilicus. This allowed placement of four interrupted sutures using the endoscopic suturing device. The patient was monitored after the procedure and she never developed peritonitis. An upper gastrointestinal series was obtained on postoperative day 3, which revealed no extravasation of contrast. Case 2: An 89-year-old woman underwent an esophagogastroduodenoscopy and EUS, which revealed a large duodenal mass and signs of gastric outlet obstruction. Upon retroflexion of the stomach, a gastric perforation was noted. The fact that this perforation could only be seen on retroflexion made the repair technically difficult. Three interrupted sutures were placed to effectively close the perforation. The patient was placed on total parenteral nutrition, while her staging work-up was completed. She then underwent a whipple procedure 1 week later to remove the duodenal mass. During the operation, the gastrotomy repair appeared intact without evidence of infection or contamination. Case 3: A 44-year-old man was found to have achalasia and underwent a peroral endoscopic myotomy (POEM). During the submucosal tunneling portion of the operation, an inadvertent gastric mucosotomy was discovered. Upon observation of the defect, the endoscopic suturing device was obtained and the mucosotomy was repaired using a running suture. The patient was discharged home on postoperative day 1 without any adverse symptoms. At 6 months after the operation, the POEM continued to be effective, adequately alleviating his symptoms of dysphagia.
Conclusions:
When recognized early, perforations of the upper gastrointestinal tract can be managed endoscopically. As shown here, endoscopic suturing platforms have the flexibility to effectively close a variety of perforations. This video demonstrates the importance of identifying extramucosal violations early and the utility of endoscopic suturing in closing them expeditiously. Familiarity with flexible endoscopic therapeutic tools, such as endoscopic suturing, is crucial in effectively managing and resolving potential complications of endoscopy.
Drs. M.A.W., L.Y.P., and N.G. have no conflicts of interest or financial ties to disclose. Dr. M.B.U. has no conflicts of interest to disclose. His financial disclosures include being a paid consultant for Olympus and a paid speaker for Apollo Endosurgery.
Runtime of video: 7 mins 37 secs
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