Over-the-scope Clip Research Articles

Efficacy and Safety of the Over-the-Scope Clip (OTSC) System in the Management of Leak and Fistula After Laparoscopic Sleeve Gastrectomy: a Systematic Review.

Endoscopic management of leaks/fistulas after laparoscopic sleeve gastrectomy (LSG) is gaining popularity in the bariatric surgery. This study aimed to review the efficacy and safety of over-the-scope-clip (OTSC) system in endoscopic closure of post-LSG leak/fistula. PubMed/Medline and major journals of the field were systematically reviewed for studies on endoscopic closure of post-LSG leaks/fistula by means of the OTSC system. A total of ten eligible studies including 195 patients with post-LSG leaks/fistula were identified. The time between LSG and leak/fistula ranged from 1day to 803days. Most of the leaks/fistula were located at the proximal staple line, and they sized from 3 to 20mm. Time between leak diagnosis and OTSC clipping ranged from 0 to 271days. Thirty-three out of 53 patients (63.5%) required one clip for closure of the lesion. Regarding the OTSC-related complications, a leak occurred in five patients (9.3%) and OTSC migration, stenosis, and tear each in one patient (1.8%). Of the 73 patients with post-LSG leak treated with OTSC, 63 patients had an overall successful closure (86.3%). OTSC system is a promising endoscopic approach for management of post-LSG leaks in appropriately selected patients. Unfortunately, most studies are series with a small sample size, short-term follow-up, and mixed data of concomitant procedures with OTSC. Further studies should distinguish the net efficacy of the OTSC system from other concomitant procedures in treatment of post-LSG leak.

Over the Scope Clip (OTSC)

Over the Scope Clip (OTSC)

First clinical experiences with a novel endoscopic over-the-scope clip system.

We describe our experience with a new over-the-scope clip (OTSC) system (Padlock Clip?) in the treatment of 14 patients. Eight of the 14 patients were treated for closure of gastrointestinal fistulas (n?=?4), iatrogenic gastrointestinal perforations (n?=?2), or hemostasis of post-polypectomy bleeding (n?=?2). The site of clipping was the lower gastrointestinal tract in five patients and the upper gastrointestinal tract in three patients. The clip was successfully delivered in seven out of the eight patients and clinical success was achieved in all patients. Endoscopic full thickness resection (EFTR) was performed to treat six patients: four with recurrent adenoma (n?=?4), one with ulcerated nodules at ileorectal anastomosis, and one with a neuro-endocrine tumor of the rectum. A complete intestinal wall resection was achieved in three of the six patients (50?%) and an R0 resection in five of the six patients (83.3?%). No complications related to the procedure and no recurrence at endoscopic follow-up were observed in any patient. The novel Padlock Clip seems to be an effective and safe tool to treat gastrointestinal fistulas, perforations or post-polypectomy bleeding, and to perform EFTR.

Over-the-scope clip closure for treatment of post-pancreaticogastrostomy pancreatic fistula: A case series.

The over-the-scope clip (OTSC) system is a recently developed endoscopic device. In the last few years, it has been successfully used for severe bleeding or deep wall lesions, or perforations of the gastrointestinal (GI) tract. We hereby report a series of patients with post-pancreaticogastrostomy pancreatic fistula in whom OTSC were used as endoscopic treatment. From January 2012 to July 2015, we prospectively collected data on cases of postoperative pancreatic fistula. These patients underwent pancreaticoduodenectomy in a high-volume center of hepatobiliopancreatic surgery. After conservative management, OTSC closure was done by single skilled operators in anesthesiologist-assisted deep sedation. A total of seven patients were enrolled. According to the International Study Group of Pancreatic Surgery criteria, we observed grade B postoperative pancreatic fistula in all cases. All patients were treated with 12/6 t-type OTSC. In two cases, asecond clip was successfully applied to a second site adjacent to the original closure site. In all cases, subsequent fluoroscopy showed no contrastographic spreading through the wall. There were no complications related to the procedure itself, not from the endoscopy point of view, nor from the anesthesiological perspective. There were no device malfunctions. Further clinical and endoscopic evaluation was made 8weeks later and showed no fistula or anastomotic defect recurrence. No patients required additional endoscopic or interventional procedures. In consideration of clinical and technical success, OTSC placement in POPF seems to be effective, safe and technically relatively easy to carry out.

Efficacy of over-the-scope clip for gastrointestinal fistula

To explore the efficacy of over-the-scope clip (OTSC) in the treatment of gastrointestinal fistula. Clinical data of 12 gastrointestinal fistula patients, including 3 internal fistula and 9 external fistula treated with OTSC in our institute from March 2015 to May 2016 were retrospectively analyzed. OTSC was performed when pus was drained thoroughly and intra-abdominal infection around gastrointestinal fistula was controlled, and each patient received one clip to close fistula. There were 6 female and 6 male patients with mean age of (50.1±12.6) years. The successful rate of endoscopic closure was 100% without complications including bleeding and intestinal obstruction during and after OTSC treatment. According to comprehensive evaluation, including drainage without digestive juices, no recurrence of intra-abdominal infection, no overflow of contrast medium during digestive tract radiography, and CT examination without intra-abdominal abscess, clinical gastrointestinal fistula closure was 91.7%(11/12). There was no recurrence of gastrointestinal fistula during 3 months of follow-up in 11 patients. In the remaining 1 case, the gastric fistula after laparoscopic sleeve gastrectomy recurred one week after OTSC treatment because of intra-abdominal infection surrounding fistula, and was cured by surgery finally. The endoscopic closure treatment of OTSC for gastrointestinal fistula is successful and effective, and control of intra-abdominal infection around fistula with adequate drainage is the key point.

Endoscopic Management of Esophageal Perforations: Who, When, and How?

Esophageal perforations can be spontaneous or iatrogenic. Although they are a rare occurrence, they are associated with a significant morbidity and mortality. Traditionally, management of esophageal perforation consisted of surgery. However, endoscopic management is now emerging as the primary treatment modality and is less invasive and morbid than surgery. Endoscopic modalities include through-the-scope clips (TTS), over-the-scope clips (OTSC), placement of covered stents, and suturing. Suturing can be used for primary closure of the perforation as well as anchoring of stents to prevent migration. Smaller defects (<2cm) can be closed with clips (TTS or OTSC), whereas larger defects require a stent placement or suturing to achieve closure. If the perforation is associated with a mediastinal collection, drainage is mandatory and can be done via CT-guided percutaneous drainage, surgery, or endoscopic vacuum therapy.

Outcomes of gastrointestinal defect closure with an over-the-scope clip system in a multicenter experience: An analysis of a successful suction method.

AIMTo demonstrate the clinical outcomes of a multicenter experience and to suggest guidelines for choosing a suction method.METHODSThis retrospective study at 5 medical centers involved 58 consecutive patients undergoing over-the-scope clips (OTSCs) placement. The overall rates of technical success (TSR), clinical success (CSR), complications, and procedure time were analyzed as major outcomes. Subsequently, 56 patients, excluding two cases that used the Anchor device, were divided into two groups: 14 cases of simple suction (SS-group) and 42 cases using the Twin Grasper (TG-group). Secondary evaluation was performed to clarify the predictors of OTSC success.RESULTSThe TSR, CSR, complication rate, and median procedure time were 89.7%, 84.5%, 1.8%, and 8 (range 1-36) min, respectively, demonstrating good outcomes. However, significant differences were observed between the two groups in terms of the mean procedure time (5.9 min vs 14.1 min). The CSR of the SS- and TG-groups among cases with a maximum defect size ≤ 10 mm and immediate or acute refractory bleeding was 100%, which suggests that SS is a better method than TG in terms of time efficacy. The CSR in the SS-group (78.6%), despite the technical success of the SS method (TSR, 100%), tended to decrease due to delayed leakage compared to that in the TG-group (TSR, CSR; 88.1%), indicating that TG may be desirable for leaks and fistulae with defects of the entire layer.CONCLUSIONOTSC system is a safe and effective therapeutic option for gastrointestinal defects. Individualized selection of the suction method based on particular clinical conditions may contribute to the improvement of OTSC success.

Successful closure of chronic, nonhealing tubercular esophagobronchial fistula with an over‑the‑scope clip

AbstractEsophagobronchial fistula is an uncommon complication of esophageal or mediastinal tuberculosis. A 35‑year‑old man, a known case of esophageal tuberculosis, who had received 9 months of antitubercular therapy (ATT) presented with persistent cough. He had previously been detected to have an esophagobronchial fistula for which multiple hemoclips had been applied elsewhere, but the fistula persisted. A fistulous communication between the esophagus and the left main bronchus was successfully closed with the help of over‑the‑scope‑clip (OTSC) system. The present case is unique as patient developed fistulous communication during the treatment with ATT and it persisted despite successful treatment of esophageal tuberculosis. Moreover, this refractory fistula could be successfully closed with OTSC.

Endoscopic Approach for Major Complications of Bariatric Surgery.

As lifestyle and diet patterns have become westernized in East Asia, the prevalence of obesity has rapidly increased. Bariatric surgeries, such as Roux-en-Y gastric bypass (RYGB), sleeve gastrectomy (SG), and laparoscopic adjustable gastric banding (LAGB), are considered the first-line treatment option in patients with severe obesity. However, postoperative complications have increased and the proper management of these complications, including the use of endoscopic procedures, has become important. The most serious complications, such as leaks and fistulas, can be treated with endoscopic stent placement and injection of fibrin glue, and a novel full-thickness closure over-the-scope clip (OTSC) has been used for treatment of postoperative leaks. Stricture at the gastrojejunal (GJ) anastomosis site after RYGB or incisura angularis in SG can be managed using stents or endoscopic balloon dilation. Dilation of the GJ anastomosis or gastric pouch may lead to failure of weight loss, and the use of endoscopic sclerotherapy, novel endoscopic suturing devices, and OTSCs have been attempted. Intragastric migration of the gastric band can be successfully treated using various endoscopic tools. Endoscopy plays a pivotal role in the management of post-bariatric complications, and close cooperation between endoscopists and bariatric surgeons may further increase the success rate of endoscopic procedures.

Endoscopic management of patients with post-surgical leaks involving the gastrointestinal tract: A large case series.

Post-surgical anastomotic leaks often require a re-intervention, are associated with a definite morbidity and mortality, and with relevant costs. We described a large series of patients with different post-surgical leaks involving the gastrointestinal tract managed with endoscopy as initial approach. This was a retrospective analysis of prospectively collected cases with anastomotic leaks managed with different endoscopic approaches (with surgical or radiological drainage when needed) in two endoscopic centres during 5 years. Interventions included: (1) over-the-scope clip (OTSC) positioning; (2) placement of a covered self-expanding metal stent (SEMS); (3) fibrin glue injection (Tissucol); and (4) endo-sponge application, according to both the endoscopic feature and patient's status. A total of 76 patients underwent endoscopic treatment for a leak either in the upper (47 cases) or lower (29 cases) gastrointestinal tract, and the approach was successful in 39 (83%) and 22 (75.9%) patients, respectively, accounting for an overall 80.3% success rate. Leak closure was achieved in 84.9% and 78.3% of patients managed by using a single or a combination of endoscopic devices. Overall, leak closure failed in 15 (19.7%) patients, and the surgical approach was successful in all 14 patients who underwent re-intervention, whilst one patient died due to sepsis at 7 days. Our data suggest that an endoscopic approach, with surgical or radiological drainage when needed, is successful and safe in the majority of patients with anastomotic gastrointestinal leaks. Therefore, an endoscopic treatment could be attempted before resorting to more invasive, costly and risky re-intervention.

Endoscopic Management of Gastrointestinal Leaks and Bleeding with the Over-the-Scope Clip: A Prospective Study.

Background/AimsThe over-the-scope clip (OTSC) is a device used for endoscopic closure of perforations, leaks and fistulas, and for endoscopic hemostasis. To evaluate the clinical effectiveness and safety of OTSC.MethodsBetween October 2013 and November 2015, 12 patients underwent OTSC placement by an experienced endoscopist. OTSC was used for the closure of gastrointestinal (GI) leaks and fistula in six patients, three of which were iatrogenic (esophageal, gastric, and duodenal) and three of which were inflammatory. In six patients, OTSC was used for hemostasis of non-variceal upper GI bleeding. Endoscopic tattooing using India ink was used to assist the accurate placement of the clip.ResultsAll subjects except one with a colonic defect experienced immediate technical success as well as long-term clinical success, during a mean follow-up of 6 weeks. Only one clip was required to close each of the GI defects and to achieve hemostasis in all patients. There were no misfirings or complications of clips. The procedure was well tolerated, and patients were hospitalized for an average of 8 days (range, 3 to 10). Antiplatelet therapy was continued in patients with GI bleeding.ConclusionsIn our experience, OTSC was safe and effective for the closure of GI defect and to achieve hemostasis of non-variceal GI bleeding.

Bleeding Duodenal Ulcer Successfully Managed with an Over-the-Scope-Clip

A 70 year-old woman was admitted for right upper quadrant pain with radiation to the back, anorexia and vomiting. Ultrasound abdomen was notable for a dilated CBD to 12mm, thickened gallbladder wall with sludge but no stones and her liver chemistries were normal. HIDA scan and MRCP were also unremarkable. On further inquiry the patient reported 7-month history of abdominal pain and had never previously had an upper endoscopy. The EGD was notable for antral erosions and a pre-pyloric 5mm clean-based ulcer in the stomach. The duodenal bulb was notable for a large 2cm posterior ulcer with large adherent clot with active bleeding (Fig. 1A). The distal duodenum demonstrated no bleeding. The endoscope was removed from the patient and an over-the-scope-clip (OTSC) or “bear claw” was applied to its distal end and the endoscope was reintroduced into the patient's abdomen. Submucosal injection of epinephrine 1:10,000 was made around the lesion with effective mucosal blanching. Then a combination of irrigation and the clear cap was used to remove most of the clot. Then the 12-3 gc OTSC was placed revealing a visible vessel centered within the bear claw (Fig. 1B), effective hemostasis was achieved. A second look EGD three days later and repeat procedure at 4 weeks demonstrated healing of the ulcer (Fig 1C,D). At the last visit an EUS was performed revealing a 10mm CBD with smooth taper to the ampulla, without choledocholithiasis and a 5mm gallbladder polyp. Gastric biopsies for helicobacter pylori were negative. The patient's pain had resolved by that time. The OTSC was designed to ensnare a large amount of tissue to facilitate closure of perforations, fistulas and anastomotic leaks. However, the nitinol made clip has seen its use expand to hemostasis and stent fixation. Posterior duodenal bulb ulcers can present a challenge for the endoscopist. The position may not provide adequate access for management with endoscopic clips or the heater probe. Clips may fall off, injuring the culprit vessel and thereby initiating a cascade of further GI bleeding. In this case, the OTSC easily achieved hemostasis. In addition to acid suppression therapy the OTSC provided adequate ulcer healing in a few days with complete resolution of the duodenal ulcer at 4 weeks. This case demonstrates the expanding role of OTSCs in the gastroenterologist's management of bleeding ulcers.Figure 1

Closing the Gap: Deployment of an Over-the-Scope Clip After Colonic Endoscopic Mucosal Resection

Background: Endoscopic mucosal resection (EMR) is an increasingly common intervention for removal of mucosal neoplasms and a popular alternative to surgical resection; especially in the setting of larger sessile polyps or laterally spreading tumors. There is a risk of post-procedure bleeding and perforation which makes closure of the mucosal defect ideal to help prevent these complications. Case: A 56 year-old male with polycystic kidney disease underwent initial routine screening colonoscopy which revealed three polyps including an 18mm sessile polyp in the ascending colon which was not removed due to high risk of bleeding and perforation. A mucosal tattoo was placed and the patient returned for repeat colonoscopy with planned EMR of the remaining polyp. The lesion was raised using methylene blue and successfully removed en bloc using a braded snare. The resulting mucosal defect was severely angulated and attempts were made to close the defect using traditional through-the-scope clips. Upon deployment several clips broke while attempting to approximate the edges of the large defect. The colonoscope was withdrawn and a standard adult gastroscope was loaded with an 11mm cap/6mm depth over-the-scope clip (OTSC). The gastroscope was able to reach the ascending colon and provide better visualization en face. The OTSC was successfully deployed resulting in complete closure of the defect without any post-procedure bleeding or complication. Discussion: As use of EMR for removal of large mucosal neoplasms has become more widespread, it has revealed that through-the-scope clips are at times limited in their application by both width of coverage and force of closure which can result in multiple clips being deployed. This can significantly increase procedure time and expense for endoscopic intervention. Data for OTSC use in this setting is limited. Recent studies have shown successful prevention of secondary perforation and bleeding after EMR with the use of an OTSC, including a European study from 2016 which demonstrated 100% technical and clinical efficacy in 10 patients who experienced incomplete wall damage during EMR. Larger scale studies are needed to validate the technique, but this case report supports the claims of recent literature.Figure 1

Endoscopic Closure of a Gastrosplenic Fistula (GSF) in a Patient with Diffuse Large B-Cell Lymphoma (DLBCL)

Gastrosplenic fistula (GSF) is a rare complication arising from malignant and less commonly benign diseases involving the stomach or spleen. Lymphoma is the most commonly associated malignancy resulting in formation of GSF. We report a unique case of GSF secondary to diffuse large B cell lymphoma (DLBCL) managed by endoscopic closure. Case Report: A 67-year-old male with rheumatoid arthritis was admitted for failure to thrive, reporting 40 lb unintentional weight loss, poor appetite, and fatigue over 3 months. He also complained of abdominal pain with oral intake. His history was negative for alcohol, tobacco, illicit drugs, and family history of malignancy. On physical exam the patient was remarkable for cachexia and a palpable tender mass in the left upper quadrant. Initial bloodwork was notable for a white blood cell count of 16.7 K/mcL, hemoglobin of 11.8 g/dL, platelets of 313 K/mcL, albumin of 2.3 g/dL. Computed tomography (CT) scan of the abdomen revealed an enlarged spleen with a 10.4 cm gas and fluid-filled, cavitary lesion and several smaller hypodensities consistent with aerosplenomegally (Image 1). CT guided fine needle aspiration was notable for foul smelling brown fluid which was submitted for gram stain, culture, and cytopathology. Subsequently a Jackson-Pratt drain was placed. Cytopathology confirmed the presence of vegetable matter (Image 3). An upper GI series and subsequent CT abdomen confirmed a GSF (Image 2). The patient was made NPO and started on total parenteral nutrition. Diagnostic upper endoscopy revealed a 9 mm clean based ulcer with irregular borders, and heaped edges 6 cm below the gastroesophageal junction on the posterior wall of the fundus. (Image 4,5). Given the amenable size of the ulcer, a 9 mm Over-The-Scope-Clip (OTSC) was deployed with closure of the defect (Image 6,7). Post procedure 1 L of methylene blue was administered orally with no dye seen in the JP drain. Repeat CT confirmed closure of the GSF. Pathology from the ulcer biopsy was consistent with DLBCL.Figure 1Figure 2Conclusion: Currently, 15 cases of GSF associated with lymphoma have been reported. Management included conservative therapy, surgical resection, chemotherapy or both when deemed feasible. This is the first ever reported case of endoscopic closure of a GSF associated with a DLBCL. Closure of the fistula was significant as it allowed the reintroduction of oral feeds to optimize the patients' nutritional status which was essential for further treatment.

The Clinical Utility of Over-the-Scope Clip for the Treatment of Gastrointestinal Defects

BackgroundThe over-the-scope clip (OTSC) is a novel endoscopic tool that enables non-surgical management of gastrointestinal (GI) defects. The aim of this study was to report our experience with OTSC for patients with GI defects. MethodsA prospectively maintained IRB-approved institutional database was queried for all patients treated with OTSC from 2012 to 2015. Primary outcome was the clinical success of the OTSC for the individual indication. Secondary outcome was the number of additional procedures needed following OTSC. ResultsFifty-one patients were treated with OTSC: upper GI (UGI) 30 and lower GI (LGI) 21. GI leak (n = 24; UGI = 12, LGI = 12) and fistulae (n = 17; UGI = 8, LGI = 9) were the most common indications. Overall success rate for the treatment of leaks was 59 % [UGI 66 % vs. LGI 33 % (p = 0.1)]. A lower success rate (35 %) was noted for fistulae [UGI 62 % vs. LGI 0 % (p = 0.001)]. Success rates for UGI perforation, bleeding, and stent anchoring indications were 75, 75, and 50 %, respectively. Additional endoscopic or surgical interventions following OTSC were indicated in 68.6 % of the patients. ConclusionsOTSC appears to have additional value in treating UGI defects. However, lower success rates for LGI defects were noted, specifically for fistulae. Most patients require an additional endoscopic or surgical procedure after one OTSC application.

Outcome, comorbidity, hospitalization and 30-day mortality after closure of acute perforations and postoperative anastomotic leaks by the over-the-scope clip (OTSC) in an unselected cohort of patients.

Acute gastrointestinal (GI) wall defects contain a high risk of morbidity and mortality and may be closed endoscopically by a full-thickness over-the-scope clip (OTSC). Unselected consecutive patients presenting with acute non-surgical perforations or postoperative anastomotic leaks or perforations underwent attempted OTSC placement as primary closure method after interdisciplinary consensus in three tertiary referral centres. Their clinical data and intervention characteristics were evaluated in an intention to treat analysis during a 24-month period to assess closure rates, 30-day mortality, hospitalization and comorbidity. In total, 34 patients (16 females, 18 males, 69.5years) were included with 22 non-surgical perforations and 12 postoperative anastomotic leaks or perforations. Definitive closure of the perforations and leaks was achieved in 26/34 patients (76.5%). Successful closure of the GI wall defect resulted in a significantly shorter hospital stay (8days, p=0.03) and was significantly correlated with comorbidity (r=0.56, p=0.005). In the group with OTSC failure, hospitalization was 18days and 6 of 8 patients (75%) required immediate surgery. Three deaths occurred in the group with successful OTSC closure due to comorbidity, while one death in the OTSC failure group was related to a refractory perforation. Favourable indications and locations for a successful OTSC procedure were identified as PEG complications, endoscopic or postoperative leaks of stomach, colon or rectum, respectively. In unselected patients, OTSC was effective for closure of acute GI wall defects in more than 75% of all patients. Clinical success and short hospitalization were best achieved in patients without comorbidity, but closure of the perforation or the anastomotic leak was found to be not the only parameter relevant for patient outcome and mortality.

Over-the-scope clip placement for closure of gastrointestinal fistula, postoperative leaks and refractory gastrointestinal bleed.

The over-the-scope clip (OTSC) has been successfully used in the closure of fistula, perforation, dehiscence, and endoscopic hemostasis. We describe our experience with the OTSC application. Between April 2014 and April 2015, seven patients underwent OTSC application. In four patients, OTSC was applied for the closure of esophageal fistula, one had OTSC closure of persistent gastrocutaneous fistula after percutaneous endoscopic gastrostomy removal, and OTSC was applied in duodenum in two patients, for duodenal Dieulafoy's lesion after failed conventional endotherapy and massive rebleed in one and duodenal perforation in another. All procedures had technical success with no immediate complication related to OTSC application. Patients were followed up for every month with mean duration of follow up 10.2months. One patient with bronchoesophageal fistula had development of another fistulous opening above the site of OTSC placement, which was successfully closed with another OTSC. One patient had superficial esophageal wall ulcer opposite the OTSC but it healed spontaneously. OTSC provided safe and successful closure in a number of settings.

Over-the-scope clip-assisted closure of colocutaneous fistula.

A 22-year-old woman sought treatment because of chronic intermittent feculent discharge through an opening on her skin in her right lower abdomen. She had received a cecostomy port at the age of 3 for chronic constipation and received an enema through the port for management of her chronic constipation. Her constipation improved with age, and the cecostomy port was subsequently removed approximately 3 years before the current presentation. Subsequently she had persistence of the fistula and had a chronic intermittent feculent discharge from the fistula opening (Fig. 1A). She did not have any other symptoms or difficulties. Colonoscopy with over-the-scope clip–assisted closure of the fistula was planned. Colonoscopy showed a normal terminal ileum and colonic mucosa. The patient was placed in the supine position, and a 0.025-inch guidewire was introduced through the cutaneous portion of the colocutaneous fistula. The guidewire was seen entering the cecum on endoscopic view, confirming the location of the colocutaneous fistula (Fig. 1B). A 12/6 type gc over-the-scope clip (OTSC) applicator cap was mounted on the tip of the endoscope (Fig. 1C). A therapeutic upper endoscope was used to match the size of the available OTSC. The endoscope was advanced to the colocutaneous fistula site, previously located with the help of a guidewire (Fig. 1D). The guidewire was removed, and a tissue grasper was used to grasp and pull the fistula opening inside the cap; subsequently, clip closure was performed (Fig. 1E). Closure of the fistula was confirmed by fluoroscopy and endoscopy because the guidewire could no longer be advanced from the cutaneous opening of the fistula (Fig. 1F). The patient was subsequently followed up 8 weeks after the procedure, and her prior symptoms of feculent discharge from the skin opening had resolved. We demonstrate successful use of over-the-scope clip application for the closure of a colocutaneous fistula (Video 1, available online at www.VideoGIE.org). All authors disclosed no financial relationships relevant to this publication. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJiZjU2ODk2MTlhZjY3ZDM0Y2VkMzg0NTY3NDg5NDcxNCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4NDcxNDg4fQ.G72DyXf488-BvtLupCKUiLr8fcPJ27M2EZGTpxTL4XFWGpRJrbdYtnTGWVwTIFeSaX6a2uNtKbKDY9fPUZJIfl3PlyAp1N86X1yM15xNYeUK2RSYciefAt5NJDgwueAW2Wwyf8HlwhtSNHEVXu00nk3ujYCkOzSIE35t9VwEG7YQs1E3xwA0f94pQI6PV0iWxRm3fpTZnFoU3eQoxffFOt7MqNS2Jh-9AZtdNI8WSzsR4c7-h1CsGzqUVkw8C-jbiwhwCNN5SRIp8CXzGwufYS73jh3oflrK42d_DpDXrqfP_aR79QftoMzfLxw5frUgsNuZdZT2sbUz48QQKDneLw Download .mp4 (52.07 MB) Help with .mp4 files Video 1Over-the-scope clip–assisted closure of colocutaneous fistula. Download .docx (.02 MB) Help with docx files Video Script

Over-the-scope clip for endoscopic closure of gastrogastric fistulae

BackgroundGastrogastric fistulae (GGF) are a well-known complication of Roux-en-Y gastric bypass (RYGB). Endoscopic approaches for closure of GGF have gained popularity, but with limited data and efficacy. ObjectivesThe primary arm of the study was to evaluate the safety and efficacy of the endoscopic closure of GGF using the over-the-scope clip (OTSC) device. SettingUniversity hospital, United States MethodsThis is a retrospective review of consecutive patients at a single academic center from September 2013 to December 2014 who underwent upper endoscopy with attempted OTSC placement for closure of GGF related to RYGB. Preprocedural, procedural, and postprocedural data were collected. Outcome measures included technical success, primary success, and long-term success. ResultsA total of 14 patients underwent attempted GGF closure using OTSC. Twelve of the 14 patients (85.7%) had technical success. Four patients were lost to follow-up. Primary success was achieved in 5 of the 10 patients (50%) in which it was assessed, either by upper gastrointestinal series or endoscopy. One of the 5 patients who had primary success was then lost to follow-up. Of the 4 patients in whom primary success was achieved and had long-term follow up, 75% (n = 3) achieved long-term success at a mean follow-up of 6.6 months from initial OTSC placement (range, 3–9), making for a long-term success rate of 33% (3/9). There were no reported complications. ConclusionOTSC closure of small GGF is feasible, safe, and offers a reasonable alternative to surgical revision. Large GGF may undergo attempted endoscopic closure, acknowledging a high failure rate.

Endoscopic full-thickness resection

Conventional endoscopic resection techniques such as endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) are powerful tools for the treatment of gastrointestinal (GI) neoplasms. However, those techniques are limited to the superficial layers of the GI wall (mucosa and submucosa). Lesions without lifting sign (usually arising from deeper layers) or lesions in difficult anatomic positions (appendix, diverticulum) are difficult - if not impossible - to resect using conventional techniques, due to the increased risk of complications. For larger lesions (>2cm), ESD appears to be superior to the conventional techniques because of the en bloc resection, but the procedure is technically challenging, time consuming, and associated with complications even in experienced hands. Since the development of the over-the-scope clips (OTSC), complications like bleeding or perforation can be endoscopically better managed. In recent years, different endoscopic full-thickness resection techniques came to the focus of interventional endoscopy. Since September 2014, the full-thickness resection device (FTRD) has the CE marking in Europe for full-thickness resection in the lower GI tract. Technically the device is based on the OTSC system and combines OTSC application and snare polypectomy in one step. This study shows all full-thickness resection techniques currently available, but clearly focuses on the experience with the FTRD in the lower GI tract.