Clip Closure Research Articles

Routine Prophylactic Clip Closure Is Cost Saving After Endoscopic Resection of Large Colon Polyps in a Medicare Population

Postprocedure bleeding remains the most common adverse event associated with endoscopic mucosal resection (EMR) of large polyps. 1 Burgess et al. Clin Gastroenterol Hepatol. 2014; 12: 651-661 Abstract Full Text Full Text PDF PubMed Scopus (141) Google Scholar Sequential placement of multiple endoclips can be used to completely close the postresection defect after endoscopic removal of a large colon polyp. Recently, 3 multicenter randomized controlled trials found that prophylactic clip closure reduces the risk of postprocedure bleeding after endoscopic resection of large colon polyps ≥20 mm in diameter. 2 Pohl H. et al. Gastroenterology. 2019; 157: 977-984 Abstract Full Text Full Text PDF PubMed Google Scholar , 3 Feagins et al. Gastroenterology. 2019; 157: 967-976 Abstract Full Text Full Text PDF PubMed Google Scholar , 4 Albéniz E. et al. Gastroenterology. 2019; 157: 1213-1221 Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar Although the clinical benefit of prophylactic clip closure in this setting is becoming more clear, deploying several endoclips often remains cost prohibitive to implement in routine practice because endoclips are not presently reimbursed by payers.

The Efficacy and Safety of a Promising Single-Channel Endoscopic Closure Technique for Endoscopic Treatment-Related Artificial Ulcers: A Pilot Study

Background/Aims: It is important to appropriately manage patients with procedure-related artificial mucosal ulcers or procedure-related complications. Many endoscopic closure techniques have been reported; however, they often require the use of special devices. We developed a single-channel endoscopic closure technique (SCCT) that can be performed with conventional devices. In the present study, we describe the technique and evaluate its efficacy. Methods: Twenty-five consecutive patients who underwent endoscopic treatment and whose artificial ulcer was closed using the SCCT were enrolled in this study. The technical success rate, number of clips for closure, procedure time, complication rate on the day of the procedure, clinical success rates on days 1 and 5, and incidence of severe stenosis of the gastrointestinal (GI) tract at 2 months after the procedure were evaluated. Results: The median ulcer diameter was 20 mm. The tumor locations were the stomach (n = 19), jejunum (n = 1), and colon (n = 5). The technical success rate was 100% (25/25), and the rate of incomplete closure was 0% (0/25). Eight clips were needed on average. The median procedure time was 18 min (range 5–49 min). The complication rate was 0% (25/25). The clinical success rates on days 1 and 5 were 100% (19/19) and 100% (9/9), respectively. No patients presented stenosis as a late complication at 2 months after the procedure (0/25). Conclusion: The SCCT could be applied in the treatment of artificial ulcers in several parts of the GI tract with a high clinical success rate and no complications. The SCCT appears to be a good option for closing artificial mucosal ulcers.

CME Exam 4: Clip Closure After Resection of Large Colorectal Lesions With Substantial Risk of Bleeding

CME Exam 4: Clip Closure After Resection of Large Colorectal Lesions With Substantial Risk of Bleeding

3161 A Rare Cause of Duodenal Perforation From Migrated Biliary Stent Managed Endoscopically

INTRODUCTION: Biliary stent migration is not uncommon (6-10%). A resultant duodenal perforation is however a rare complication (<1%) often associated with significant morbidity and can require surgery. Here we present a rare case of a duodenal perforation from plastic stent migration which was successfully managed endoscopically with through-the-scope (TTS) clips. CASE DESCRIPTION/METHODS: A 75 years old lady with history of painless obstructive jaundice, CT imaging with a hilar soft tissue mass and intrahepatic biliary dilation underwent endoscopic ultrasound (EUS) and endoscopic retrograde cholangiography (ERCP). A 7 Fr × 15 cm plastic biliary stent was placed into the right system after sphincterotomy and stricture dilation. The left system could not be accessed. Post procedure liver chemistries improved and she was discharged on antibiotics with close follow up. Patient developed lower abdominal pain and presented to the emergency department approximately 48 hours after ERCP. CT abdomen revealed biliary stent migration with concern for duodenal perforation and extraluminal air with heterogenous free fluid. Emergent upper endoscopy (EGD) showed migration of plastic biliary stent with distal tip protruding through the lateral wall of the second portion of the duodenum. The stent was removed using rat-tooth forceps revealing a 3 mm mucosal defect which was closed with TTS clips. Hospital course was complicated by fevers and repeat imaging showed increasing size of air and fluid collection. Repeat EGD showed a visible area of leakage on one edge of the previously repaired perforation. This was closed with hemostatic clips. Small bowel follow through studies at day 3 and 7 post procedure confirmed no contrast extravasation to suggest a persistent duodenal leak. Her diet was advanced and she was discharged with clinic follow up. DISCUSSION: Duodenal perforation from biliary stent migration is rare and limited case reports present the use of TTS clips in endoscopic management. In our patient the plastic biliary stent was endoscopically visualized protruding through the opposite wall of the duodenum while the proximal end was still in the biliary tree, likely creating enough force to cause a perforation. Although the initial attempted closure with TTS clips revealed no leakage immediately post procedurally, there was persistent leakage requiring repeat endoscopy and further clips for closure. A high morbidity surgical procedure can be avoided by this endoscopic approach even if there is a recurrence of leakage.

1893 Non-Surgical Endoscopic Management of a Sealed Nail Perforation in the Gastric Antrum

INTRODUCTION: Foreign body ingestions are most commonly seen in children, elderly adults, and patients with psychiatric conditions. Perforation is a feared complication, often requiring surgical intervention. We present a case of endoscopic removal of a sealed nail perforation with an over-the-scope clip closure in a patient who was a high-risk surgical candidate. CASE DESCRIPTION/METHODS: A 48-year-old homeless male with a history of multiple abdominal surgeries due to gunshots and stab wounds complicated by abdominal hernias presented with 1 week of abdominal pain after drinking an open bottle of soda. Vital signs were stable on presentation. Labs were unremarkable. Computed tomography (CT) revealed a needle-like foreign body in the antrum of the stomach that appeared to project beyond the lumen without signs of pneumoperitoneum free perforation or fluid (Figure 1). An upper endoscopy was performed to further characterize the foreign body. Upon entering the stomach, a 2mm round metallic circular object (Figure 2) was visualized along the lesser curvature of the antrum, suggestive of a nail embedded into the gastric antrum. General surgery was consulted given concern for perforation, however, the patient was deemed a high-risk surgical candidate due to hostile abdominal scarring. The decision was made for endoscopic repair of the nail perforation. On repeat endoscopy, the nail was again visualized in the lesser curve of the antrum; rat-tooth forceps were used to remove a 2.8cm rusty nail (Figure 3) which was safely pulled through an overtube. The scope was reinserted with an over-the-scope clip attached, which was then successfully deployed at the site of perforation. Patient tolerated the procedure well with no signs of peritonitis and follow-up CT four days post-procedure showed the clip in place. DISCUSSION: Complications such as perforations and abscesses occur in less than 1% of foreign body ingestions. The most common sites of perforation are the ileocecal valve and other points of intestinal angulations. There are limited cases in the literature of endoscopic intervention in a sealed nail perforation in the stomach in an adult. We found that an over-the-scope clip was effective in sealing a small perforation without evidence of peritonitis on follow-up examinations. Coordination with the surgical service is important in endoscopic repair of perforations. Overall, endoscopic removal of a sealed nail perforation is a viable option for high-risk patients.

1758 H-type Tracheoesophageal Fistula: A Rare Cause of Cough and Dysphagia in Adults

INTRODUCTION: Tracheoesophageal fistula (TEF) without associated esophageal atresia (H-type) is a rare congenital anomaly, accounting for ∼4% of esophageal malformations. It is defined as a connection between the posterior tracheal and anterior esophageal walls and is typically diagnosed before age 3. However, it can occasionally be seen in adults with chronic cough and respiratory infections. We present a 38-year-old female with a new diagnosis of H-type TEF. CASE DESCRIPTION/METHODS: A 38-year-old female (G16P12-0-3-12) with multiple prior admissions for hypoxia (presumed due to asthma and aspiration in the setting of achalasia) was admitted with HELLP syndrome. Prior pulmonary function tests showed severe airway obstruction and echocardiogram showed normal left and right ventricular systolic function. She reported coughing when supine and with meals, a history of congenital lung abnormality, severe infancy pneumonia, upper lobe resection, diagnosis of achalasia, and yearly admissions for pulmonary issues. After delivery, she was transferred to the pulmonary service for management of her hypoxia. A TEF without inflammation was noted on chest CT and confirmed by EGD and bronchoscopy. EGD showed a 3 mm proximal esophageal fistula. Bronchoscopy demonstrated a normal oropharynx and vocal cords (VC), erythematous larynx, inflamed arytenoids, a 4 mm proximal TEF without mucosal abnormalities, and right upper lobe (RUL) absence. A swallow study showed aspiration on the posterior side of the trachea presumed due to the TEF. Surgical repair rather than endoscopic clip or stent placement was determined to be the best treatment via cervical approach esophagoplasty, muscle flap reconstruction TEF repair, and laparoscopic Heller myotomy with Dor fundoplication. DISCUSSION: H-type TEF is rare and can mimic chronic lung disease due to aspiration, recurrent infection, and bronchiectasis. It must be considered in adults with recurrent respiratory infections, coughing with eating/drinking, and rarely, hemoptysis. A chest CT, bronchoscopy, esophagoscopy, and barium study are crucial to confirm the diagnosis. While endoscopic clip closure of fibrotic TEFs has been successful in 62%, it may obliterate surgical tissue planes. Surgery is the optimal treatment for H-type TEF and reported to be 75-94% successful. As H-type TEF disrupts myenteric plexus development with impaired esophageal peristalsis and lower sphincter dysfunction, a Heller myotomy and Dor fundoplication should be offered.

Clip Closure After Resection of Large Colorectal Lesions With Substantial Risk of Bleeding

It is not clear whether closure of mucosal defects with clips after colonic endoscopic mucosal resection (EMR) prevents delayed bleeding, although it seems to have no protective effects when risk is low. We performed a randomized trial to evaluate the efficacy of complete clip closure of large (≥2 cm) nonpedunculated colorectal lesions after EMR in patients with an estimated average or high risk of delayed bleeding. We performed a single-blind trial at 11 hospitals in Spain from May 2016 through June 2018, including 235 consecutive patients who underwent EMR for large nonpedunculated colorectal lesions with an average or high risk of delayed bleeding (based on Spanish Endoscopy Society Endoscopic Resection Group score). Participants were randomly assigned to groups that received closure of the scar with 11-mm through-the-scope clips (treated, n= 119) or no clip (control, n= 116). The primary outcome was proportion of patients in each group with delayed bleeding, defined as evident hematochezia that required medical intervention within 15 days after colonoscopy. In the clip group, complete closure was achieved in 68 (57%) cases, with partial closure in 33 (28%) cases and failure to close in 18 (15%) cases. Delayed bleeding occurred in 14 (12.1%) patients in the control group and in 6 (5%) patients in the clip group (absolute risk difference, reduction of 7% in the clip group; 95% confidence interval, -14.7% to 0.3%). After completion of the clip closure, there was only 1 (1.5%) case of delayed bleeding (absolute risk difference, reduction of 10.6%; 95% confidence interval, -4.3% to 17.9%). In a randomized trial of patients with large nonpedunculated colorectal lesions undergoing EMR, we found that clip closure of mucosal defects in patients with a risk of bleeding can be a challenge, but also reduces delayed bleeding. Prevention of delayed bleeding required complete clip closure. ClinicalTrials.gov ID: NCT02765022.

Over-the-Scope Clip Closure of Pancreatico-Colonic Fistula Secondary to Acute or Chronic Pancreatitis: A Case Series.

Introduction: Pancreatico-colonic fistula (PCF) is a rare adverse effect secondary to severe acute or chronic pancreatitis and potentially life-threatening because of abdominal sepsis. Over-the-scope clip (OTSC®) system is a recently developed endoscopic device and has been successfully used for bleeding and perforations of the gastrointestinal tract. We hereby report a series of patients with PCFs in whom OTSC was used. Materials and Methods: From January 2011 to December 2018, we retrospectively collected data on cases of PCFs with endoscopic treatment using the OTSC system. After conservative management, the endoscopic intervention was carried out on patients in deep sedation by single skilled operators. Results: A total of 9 patients were enrolled and patients were treated with 14/6 t-type OTSC. PCF occurred secondary to chronic (n = 5) and acute pancreatitis (n = 4). There were no adverse effects related to the endoscopic procedure itself. Further endoscopic evaluation was performed 8 weeks later and revealed a successful fistula closure in 4 patients with chronic pancreatitis (80%) and in 2 patients with acute pancreatitis (50%). An insufficient fistula closure was observed in 3 cases because of dislocation of the OTSC and an additional surgical procedure was required. Conclusion: The OTSC system seems to be safe and effective in short-term management of PCFs because of acute or chronic pancreatitis in addition to the already established nonsurgical therapy. However, the OTSC closure of PCFs in patients with acute pancreatitis seems to be associated with a higher failure rate. To sum up, more evidence and long-term studies are needed to determine the criteria for the use of OTSC in closure of PCFs owing to acute or chronic pancreatitis.

Management of adverse events related to endoscopic resection of upper gastrointestinal neoplasms: Review of the literature and recommendations from experts.

Prevention therapy is recommended for lesions >1/2 of the esophageal circumference. Locoregional steroid injection is recommended for lesions >1/2-3/4 of the esophageal circumference and oral steroids are recommended for lesions >1/2 of the subtotal circumference. For lesions of the entire circumference, oral steroid combined with injection steroid is considered. Endoscopic balloon dilatation (EBD) is the first choice of treatment for stricture after esophageal endoscopic submucosal dissection (ESD). Radical incision and cutting or self-expandable metallic stent can be considered for refractory stricture after EBD. In case of intraoperative perforation during esophageal ESD, endoscopic clip closure should be initially attempted. Surgery is considered for treatment of delayed perforation. Current standard practice for prevention of delayed bleeding after gastric ESD includes prophylactic coagulation of vessels on post-ESD ulcers and giving proton pump inhibitors. Chronic kidney disease stage 4 or 5, multiple antithrombotic drug use, anticoagulant use, and heparin bridging therapy are high-risk factors for delayed bleeding after gastric ESD. Intraoperative perforation during gastric ESD is initially managed by endoscopic clip closure. If endoscopic clip closure is difficult, other methods such as over-the-scope clip (OTSC), polyglycolic acid (PGA) sheet shielding etc. are attempted. Delayed perforation usually requires surgical intervention, but endoscopic closure by OTSC or PGA sheet may be considered. Resection of three-quarters of the circumference is a risk factor for stenosis after gastric ESD. Giving prophylactic local steroid injection and/or oral steroid is reported, but effectiveness has not been fully verified as has been done for esophageal stricture. The main management method for gastric stenosis is EBD but it may cause perforation.

Clip Closure for Postpolypectomy Bleeding Prevention

After endoscopic resection of large colorectal polyps, closing polypectomy defects with clips is thought to decrease severe bleeding risk, but

Clip Closure Prevents Bleeding After Endoscopic Resection of Large Colon Polyps in a Randomized Trial

Bleeding is the most common severe complication after endoscopic mucosal resection of large colon polyps and is associated with significant morbidity and cost. We examined whether prophylactic closure of the mucosal defect with hemoclips after polyp resection reduces the risk of bleeding. We performed a multicenter, randomized trial of patients with a large nonpedunculated colon polyp (≥20 mm) at 18 medical centers in North America and Spain from April 2013 through October 2017. Patients were randomly assigned to groups that underwent endoscopic closure with a clip (clip group) or no closure (control group) and followed. The primary outcome, postprocedure bleeding, was defined as a severe bleeding event that required hospitalization, a blood transfusion, colonoscopy, surgery, or another invasive intervention within 30 days after completion of the colonoscopy. Subgroup analyses included postprocedure bleeding with polyp location, polyp size, or use of periprocedural antithrombotic medications. We also examined the risk of any serious adverse event. A total of 919 patients were randomly assigned to groups and completed follow-up. Postprocedure bleeding occurred in 3.5% of patients in the clip group and 7.1% in the control group (absolute risk difference [ARD] 3.6%; 95% confidence interval [CI] 0.7%-6.5%). Among 615 patients (66.9%) with a proximal large polyp, the risk of bleeding in the clip group was 3.3% and in the control group was 9.6% (ARD 6.3%; 95% CI 2.5%-10.1%); among patients with a distal large polyp, the risks were 4.0% in the clip group and 1.4% in the control group (ARD -2.6%; 95% CI -6.3% to -1.1%). The effect of clip closure was independent of antithrombotic medications or polyp size. Serious adverse events occurred in 4.8% of patients in the clip group and 9.5% of patients in the control group (ARD 4.6%; 95% CI 1.3%-8.0%). In a randomized trial, we found that endoscopic clip closure of the mucosal defect following resection of large colon polyps reduces risk of postprocedure bleeding. The protective effect appeared to be restricted to large polyps located in the proximal colon. ClinicalTrials.gov no: NCT01936948.

Endoscopic technique for closure of enterocutaneous fistulas.

Endoscopic over the scope clip (OTSC) closure represents a new technique for endoscopic management of enteric bleeding and tissue defects such as anastomotic leaks and enterocutaneous (EC) fistulas. We aim to describe our technical approach for OTSC closure of EC fistulas and convey our outcomes. This retrospective review includes ten patients who underwent OTSC application for EC fistulas by surgical endoscopists at a US tertiary care hospital from July 2015 to October 2017. Demographic data, along with type of defect, location, duration of lesion, success or failure of OTSC, and nutritional status were compiled. The ACS NSQIP surgical risk calculator was used to project the risk of mortality, complications, length of stay, and risk of readmission had our patients undergone surgical correction of their fistula. Overall success for EC fistula closure was 70%. Acute fistulas were closed with a success rate of 86%. Chronic fistulas were closed successfully in only 33% of cases. Of patients successfully closed, NSQIP-predicted rates of mortality, any complication, and median length of stay were 21.1%, 34.5%, and 9.5days, respectively. With OTSC, these patients experienced 0 mortalities, 0 complications, and had a median length of stay of 4days. OTSC is an effective adjunctive measure to improving rates of successful closure of EC fistulas and compromised anastomosis. OTSC conveys a markedly improved procedural risk profile as compared to standard surgical correction.

Submucosal per-oral endoscopic myotomy for a large Zenker’s diverticulum with use of a hydrodissector knife and an over-the-scope clip closure

Submucosal per-oral endoscopic myotomy for a large Zenker’s diverticulum with use of a hydrodissector knife and an over-the-scope clip closure

Systematic review of cystic duct closure techniques in relation to prevention of bile duct leakage after laparoscopic cholecystectomy.

AIMTo study the effect of different techniques of cystic duct closure on bile leakage after laparoscopic cholecystectomy (LC) for biliary disease.METHODSA systematic search of MEDLINE, Cochrane and EMBASE was performed. Rate of cystic duct leakage (CDL) was the primary outcome. Risk of bias was evaluated. Odds ratios were analyzed for comparison of techniques and pooled event rates for non-comparative analyses. Pooled event rates were compared for each of included techniques.RESULTSOut of 1491 articles, 38 studies were included. A total of 47491 patients were included, of which 38683 (81.5%) underwent cystic duct closure with non-locking (metal) clips. All studies were of low-moderate methodological quality. Only two studies reported separate data on uncomplicated and complicated gallbladder disease. For overall CDL, an odds ratio of 0.4 (95%CI: 0.06-2.48) was found for harmonic energy vs clip closure and an odds ratio of 0.17 (95%CI: 0.03-0.93) for locking vs non-locking clips. Pooled CDL rate was around 1% for harmonic energy and metal clips, and 0% for locking clips and ligatures.CONCLUSIONBased on available evidence it is not possible to either recommend or discourage any of the techniques for cystic duct closure during LC with respects to CDL, although data point out a slight preference for locking clips and ligatures vs other techniques. No separate recommendation can be made for complicated gallbladder disease.

Wound Closure after Thyroid and Parathyroid Surgery: A Meta-Analysis of Randomized Controlled Trials.

Wound closure after thyroidectomy and parathyroidectomy is associated with patients' satisfaction, perception of cosmetic appearance, and experience of postoperative pain. Subcutaneous sutures, clips, and tissue adhesive are the three major methods of wound closure. In this study, we conducted a meta-analysis of randomized controlled trials to evaluate the outcomes of these methods. Relevant studies published before December 2017 were identified from PubMed, Embase, Cochrane Library, Scopus, and the ClinicalTrials.gov registry. Individual effect sizes were standardized, and a meta-analysis was conducted to calculate the pooled effect size by using random-effect models. The primary outcome was the cosmetic appearance, which was evaluated 4 weeks, 6 weeks, and 6 months after surgery. The secondary outcomes were patient satisfaction, postoperative pain, and complications. A total of nine trials with 612 patients were reviewed. No significant difference was observed in patient satisfaction, postoperative pain, and complications among the wound closure methods. However, according to surgeon assessment, the subcutaneous suture method resulted in a significantly more favorable cosmetic appearance than the clip method (mean difference: -1.47, 95% confidence interval: -2.72 to -0.23). In the current study, no differences were found in patient satisfaction and postoperative pain among the subcutaneous suture, clip, and tissue adhesive wound closure methods. However, surgeons provided a more favorable appraisal for the subcutaneous suture method because of the improved cosmetic appearance. The choice of the closure method should be based on surgeon's preference and cost.

Feasibility of endoscopic mucosa-submucosa clip closure method (with video).

Abstract Background and study aims We developed a new endoscopic closure technique using just conventional endoclips. The feasibility of endoscopic mucosa-submucosa clip closure method was evaluated in this clinical pilot study. Patients and methods This study involved consecutive 25 patients who underwent colorectal endoscopic submucosal dissection. Endoclips were placed at the edge of the mucosal defect. Each arm of the endoclip gripped the mucosa and submucosa, respectively. The direction in which the endoclip grips were placed was parallel to the short axis of the defect. Several endoclips were applied in this way. As a result, the mucosal defect was significantly reduced in size. Additional clips were placed to achieve complete closure. Results Mean size of resected specimen was 31.2 ± 11 mm. The success rate was 96 % (24/25). Mean procedure time was 9.6 ± 4.4 minutes. Mean number of endoclips was 9.3 ± 3.7. No complications were observed in any of the patients after the procedure. Conclusion Endoscopic mucosa-submucosa clip closure method could close mucosal defect of size around 2 – 4 cm completely using just conventional endoclips, and it seems easy, simple and low cost.

Endoscopic purse-string suturing with multiple over-the-scope clips for closure of a large mucosal defect after duodenal endoscopic submucosal dissection

Endoscopic purse-string suturing with multiple over-the-scope clips for closure of a large mucosal defect after duodenal endoscopic submucosal dissection

Endoscopic purse-string suturing with an over-the-scope clip for closure of a large mucosal defect after gastric ESD

Endoscopic purse-string suturing with an over-the-scope clip for closure of a large mucosal defect after gastric ESD

886 - Clip Closure after Endoscopic Resection of Large Intestinal Polyps: A Randomized Trial (Clip Trial)

886 - Clip Closure after Endoscopic Resection of Large Intestinal Polyps: A Randomized Trial (Clip Trial)

Prophylactic clip closure may reduce the risk of delayed bleeding after colorectal endoscopic submucosal dissection.

Background and study aims Endoscopic submucosal dissection (ESD) has a high en bloc resection rate and is widely performed for large superficial colorectal tumors, but delayed bleeding remains one of the most common complications of colorectal ESD. The aim of the present study was to evaluate the clinical efficacy of prophylactic clip closure of mucosal defects for the prevention of delayed bleeding after colorectal ESD. Patients and methods We enrolled consecutive patients with colorectal lesions between January 2012 and May 2017 in this retrospective study. In the early part of this period, post-ESD mucosal defects were not closed (non-closure group); however, from January 2014, post-ESD mucosal defects were prophylactically closed with clips when possible (closure group). The main outcome measured was delayed bleeding. Variables were analyzed using the chi-squared test, Fisher’s exact test, or Student’s t-test. Results Of 156 lesions analyzed, 61 were in the non-closure group and 95 in the closure group. Overall, delayed bleeding occurred in 5 cases (3.2 %). The delayed bleeding rate was 0 % (0/95) in the closure group and 8.2 % (5/61) in the non-closure group ( P = 0.008). The mean procedure time for closure was 10.4 ± 4.6 min (range 3 – 26 min). Conclusions We demonstrated that prophylactic clip closure of mucosal defects might reduce the risk of delayed bleeding after colorectal ESD.