Efficacy and safety of over-the-scope clip: including complications after endoscopic submucosal dissection

Abstract

Aim: To retrospectively review the results of over-the-scope 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.

Keywords: Endoscopic submucosal dissection complications; Gastrointestinal bleeding; Gastrointestinal fistulae; Gastrointestinal perforation; Over-the-scope clip.

Figure 1

Esophageal perforation caused by a nasogastric tube. A: During the insertion of a nasogastric tube, the tip of the tube perforated the lower esophagus; B: The wound was successfully closed with a single over-the-scope clip, and there was no leakage.

Figure 2

Gastrocutaneous fistula that occurred after percutaneous endoscopic gastronomy removal. A: After the removal of a gastrostomy tube, the patient was able to eat orally, but a gastrocutaneous fistula was diagnosed; B: The wound was slightly hardened, but was successfully closed with a single over-the-scope clip.

Figure 3

A gastric tube bronchial fistula following a subtotal esophagectomy for esophageal cancer. A: A gastric tube bronchial fistula occurred after a subtotal esophagectomy for esophageal cancer. Bronchial embolization was performed, but it failed to close the fistula; B: The authors attempted to close the fistula using over-the-scope clip (OTSC) but were unsuccessful. Although 1 OTSC was placed, mucosal hardening (resulting from the prolonged duration of the untreated ulcer) prevented the placement of the additional OTSCs required for closure; C: A chest-abdominal computed tomography scan revealed a gastrobronchial fistula (arrow).

Figure 4

Iatrogenic perforation after endoscopic submucosal dissection for early gastric cancer in the greater curvature of the stomach. A: A post-endoscopic submucosal dissection ulcer was found in the greater curvature of the stomach. An examination by retroflex view revealed that the muscle layer was separated and perforated; B: The wound was successfully closed using an over-the-scope clip (OTSC). An upper endoscopy performed 2 mo after the closure revealed no displacement of the OTSC or complications, such as ulceration or deformation.

Figure 5

Bleeding from an anastomotic ulcer caused by a sigmoidectomy for sigmoid cancer. A: Bleeding was observed from the anastomotic site after surgery for sigmoid colon cancer; B: The wound was successfully closed using an over-the-scope clip; C: The postoperative course has been uneventful, with no rebleeding.