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(A, B) Peritoneal fat observed during advancement of the endoscope, consistent with full-thickness perforation.
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Background
Less invasive and safer anastomotic techniques are desirable. We aimed to determine technical feasibility and safety of sutureless duodeno-ileal side-to-side anastomosis in obese patients using self-assembling magnets.Methods
This was an open-label, prospective, and single-arm study including obese patients (BMI 30–50 kg/m2) with type II...
Congenital duodenal obstruction is a common cause of bowel obstruction. It is relatively easy to diagnose in the neonatal period. However, if the obstruction is due to a duodenal diaphragm, diagnosis may be delayed until later in infancy or even adulthood, depending on the size of the aperture in the diaphragm. Congenital duodenal obstruction may b...
Citations
... 1-4). The use of OTSC for the closure of upper gastrointestinal iatrogenic perforation has been reported to decrease the proportion of patients requiring surgery from 62.5% to 12.5% in a retrospective study by Khater et al. 40 Endoscopic suturing via an over-the-scope suturing device has also been described for the closure of iatrogenic perforations in the duo- 41 More recently, Zhang et al. 42 described the use of a novel through-the-scope suturing device to close iatrogenic duodenal defects, potentially obviating the additional step of removing the endoscope from the patient to affix the device. Surgical repair is required immediately in cases where endoscopic measures fail. ...
Endoscopic retrograde cholangiopancreatography (ERCP) plays a crucial role in the management of pancreaticobiliary disorders. Although the ERCP technique has been refined over the past five decades, it remains one of the endoscopic procedures with the highest rate of complications. Risk factors for ERCP-related complications are broadly classified into patient-, procedure-, and operator-related risk factors. Although non-modifiable, patient-related risk factors allow for the closer monitoring and instatement of preventive measures. Post-ERCP pancreatitis is the most common complication of ERCP. Risk reduction strategies include intravenous hydration, rectal nonsteroidal anti-inflammatory drugs, and pancreatic stent placement in selected patients. Perforation is associated with significant morbidity and mortality, and prompt recognition and treatment of ERCP-related perforations are key to ensuring good clinical outcomes. Endoscopy plays an expanding role in the treatment of perforations. Specific management strategies depend on the location of the perforation and the patient's clinical status. The risk of post-ERCP bleeding can be attenuated by preprocedural optimization and adoption of intra-procedural techniques. Endoscopic measures are the mainstay of management for post-ERCP bleeding. Escalation to angioembolization or surgery may be required for refractory bleeding. Post-ERCP cholangitis can be reduced with antibiotic prophylaxis in high risk patients. Bile culture-directed therapy plays an important role in antimicrobial treatment.
Video
Video 1
Management of an acute perforated duodenal ulcer.
Introduction
OverStitch endoscopic suturing enables advanced closure by tissue approximation via endoscopically placed sutures with the ability to customize suture patterns. Newer OverStitch generation also known as OverStitch Sx overcame the limitation of the previous generation and is compatible with 20 single channel scopes over four platforms with greater maneuverability and visibility.
Areas covered
In this article we will focus on the differences between three generations of OverStitch. In addition, we will review existing literature on the efficiacy of OverStitch in the management of full thickness defect closure, fistula and leaks repair, stent fixation and bariatric surgeries along with its complications and limitations.
Expert opinion
Assembling overstitch takes less than five minutes and the correct sequence of system assembly is the key for a successful procedure. Transition from the second generation OverStitch to OverStitch Sx may require 3 to 5 cases for learning curve.
Endoscopic suturing allows for select patients with perforations, leaks, and fistulas to be managed endoscopically. Experience with the Overstitch endoscopic suturing device suggests it may be superior to endoclips in the management of perforations, because of its ability to achieve full-thickness suturing and create an airtight closure. Although successful closure of leaks and fistulas using the Overstitch device has been described, additional therapy with a multimodality approach is often required because of inherent challenges with fistula recurrence. This article reviews the existing literature on the Overstitch endoscopic suturing system specifically in the management of gastrointestinal perforations, leaks, and fistulas.
Iatrogenic perforations related to endoscopic retrograde cholangiopancreatography (ERCP) are an uncommon adverse event, occurring in 0.14–1.3% of cases, and are associated with a mortality of up to 8%. The most widely utilized classification system was proposed by Stapfer et al. and characterizes perforations based on mechanism and location. Type I perforations occur on the lateral duodenal wall secondary to endoscope trauma, type II are sphincterotomy-related, type III are perforations of the bile duct or pancreatic duct with endoscopic tools, and type IV are miniscule and identified with free air on fluoroscopic imaging. Studies utilizing this classification system demonstrate that patients with type III and IV perforations do well with conservative management alone, whereas patients with type I and II perforations frequently require surgical management and are more likely to have poor outcomes. There remain many unanswered questions pertaining to the exact role of surgical, endoscopic, and medical therapy, especially in patients with type I, II, and III perforations. In this chapter we will focus on perforation related to ERCP, outlining a diagnostic and management strategy as it pertains to classification, and emphasize a management algorithm that can be used to better approach this serious adverse event.
