One hundred and one over-the-scope-clip applications for severe gastrointestinal bleeding, leaks and fistulas

Abstract

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-threatening 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.

Keywords: Endoscopic therapy; Fistula; Gastrointestinal bleeding; Over-the-scope-clip; Perforation.

Figure 1

Ulcer (Forrest IIa) at the gastric angulus (A-D). Acute bleeding after attempt of closure of the visible vessel using a standard hemoclip. Successful hemostasis using a 12/6t over-the-scope-clip.

Figure 2

Severe recurrent ulcer bleeding from the gastroduodenal artery at the posterior wall of the duodenal bulb despite primary endoscopic clipping and surgical oversewing (A-D). Visible surgical threads at the ulcer base (A); Intermittent massive re-bleeding at rinsing and suction (B); Successful application of a 12/6t Over-the-Scope-Clip by pulling the ulcer bed into the transparent distal attachment cap (C, D).

Figure 3

Acute perforation after endoscopic mucosal resection of a 2 cm tubulovillous adenoma at the right colonic flexure (A-I). Successful closure of the large defect using two large 14/6t over-the-scope-clips applied side-to-side.