Repair of Bowel Perforation: Endoscopic State of the Art

Abstract

Background: Intestinal damage from various etiologies can result in the potentially dangerous complication of bowel perforation. Emergent treatment of small bowel perforation includes surgical repair with or without small bowel resection. As the number of therapeutic and diagnostic endoscopic procedures increase, more studies may be required to properly evaluate and report incidences of bowel perforation. Given the advantages of interventional procedures, novel endoscopic technologies which may prove beneficial in bowel perforation repair are continuously undergoing development. Bowel perforation can lead to peritonitis and sepsis – a medical emergency requiring immediate attention. Following diagnosis, hemodynamically stable patients may be treated conservatively whereas unstable patients undergo more intensive surgical procedures. Endoscopic procedures for bowel perforation repair also exist and recent advances in technology are furthering the scope of such closure methods. Methods and Findings: Endoscopic suturing technologies, while capable, require extensive training and entail prolonged activation processes. Wound vacuum sponge closure via endoscopy provides convergence of wound defects but may not be efficacious in defects larger than 5 cm. Furthermore, this method may be limited by inadequate seal and placement in the intestine. Endoscopic clipping is another modality beneficial for smaller perforations only. T-tag suturing has shown promising results in ex-vivo studies but entails blind placement of T-tags for perforation closure. Stents can be inserted endoscopically under fluoroscopic visual guidance. This technique, however, may result in stent migration, perforations and potential occlusions. Sealants can be injected for perforation closure but have not demonstrated clear efficacy. Robotic flexible endoscopy provides several novel features yet may require advanced training and sometimes more than one operator. As interventional procedures continue to gain popularity, a better understanding of endoscopic modalities is helpful for furthering their development. Regarding bowel perforation, this review aids in an overall understanding of the technologies which exist and are advancing further into more standard modalities for practical medical applications. Conclusion: There are currently various methods to repair perforation of the gastrointestinal wall and except for urgent exploratory laparotomy when indicated, there is likely no single method that is superior to others. It may be beneficial for the physician to consider all options for repair when evaluating a potential bowel perforation, considering physician preference and individual success or difficulty with a given modality. In more recent years as the focus has narrowed on minimally invasive procedures, future modalities will likely include increased automation and ease of use with the help of robotics, which will hopefully lead to decreased time to diagnosis, faster recovery and reduced morbidity and mortality.