Endoscopic Closure of Persistent Anastomotic Leaks Using the US Endoscopy Padlock® Over-the-Scope Clip

Abstract

Introduction: Persistent anastomotic leaks (PAL) are an uncommon but serious surgical complication associated with significant morbidity and mortality. While traditionally treated by percutaneous drainage and surgical revision, there is an emerging paradigm for endoscopic management using over-the-scope clips (OTSC). We present 4 cases of PAL that were endoscopically treated using the US Endoscopy Padlock® OTSC. Case Presentations: Case 1: A 57-year-old man with sigmoid adenocarcinoma underwent laparoscopic left hemicolectomy complicated by dehiscence at the anastomosis resulting in fluid collection needing percutaneous drainage. A fistulous tract was found at the proximal sigmoid colon anastomosis communicating to the retroperitoneum. Over the course of 3 endoscopies, Padlock OTSCs were used to close the defect. No evidence of PAL noted on follow-up colonoscopy or on subsequent abdominal imaging. Case 2: A 54-year-old man with Lynch syndrome and colon adenocarcinoma underwent total colectomy with ileorectal anastomosis complicated by PAL requiring percutaneous drains. Two openings were noted along the staple line and Padlock® OTSC was applied on each site. No evidence of PAL on follow-up imaging. Case 3: A 55-year-old man with perforated sigmoid diverticulitis underwent diverting colostomy and eventual takedown complicated by a large PAL resulting in multiple pelvic abscesses, for which percutaneous drains were placed. A 2 cm opening was seen distal to the colorectal anastomosis that was closed with adjacent Padlock® OTSCs x2. Subsequent imaging confirmed successful endoscopic closure. Case 4: A 48-year-old woman with sigmoid adenocarcinoma underwent sigmoid colectomy complicated by peritonitis and PAL requiring diverting loop ileostomy. A 2 mm leak was identified along the anastomosis in the proximal rectum and closed using Padlock® OTSC. No evidence of PAL was noted on the follow-up imaging. Discussion: Anastomotic leaks and fistulas are serious post-operative complications that cause significant patient morbidity, prolonged hospitalizations, and multiple invasive interventions. We presented 4 cases of successful endoscopic closure of both small (< 5 mm) and large (>20 mm) anastomotic leaks using the US Endoscopy Padlock® OTSC. Our experience indicates that this novel device is easy to use, minimally invasive, and cost effective, therefore should be considered as an alternative to surgery for closure of anastomotic leaks and fistulae within the GI tract.2105_A Figure 1. (A & B) closure of persistent anastomotic leaks using the US Endoscopy Padlock® over —the-scope clip (A: before the closure; B: after the closure).2105_B Figure 2. (A & B) closure of persistent anastomotic leaks using the US Endoscopy Padlock® over —the-scope clip (A: before the closure; B: after the closure).