Resolution Clips Research Articles

Through-the-scope clip retention rates and performance in a porcine model.

Background and study aims Limited comparative data exist to guide optimal through-the-scope (TTS) clip selection. The aim of this study was to compare the efficacy, retention, and safety of three industry-leading TTS clips on tissue that mimics common clinical scenarios. Methods A survival study involving six domestic pigs was undertaken. Three commonly used clip models were selected: Assurance (STERIS, Mentor, Ohio, United States), Resolution (Boston Scientific, Boston, Massachusetts, United States), and SureClip (Micro-Tech, Ann Arbor, Michigan, United States). To mimic clinical practice, the following scenarios were assessed: (1) normal mucosa; (2) cold snare resection; and (3) hot mucosal resection simulating fibrotic ulcers. Deployment of clips was randomized to target sites. Repeat endoscopy was performed 2 weeks following placement. Endoscopists rated the ease of use of clip placement on a Likert scale of 1 to 5. Results Fifty-four clips (18 Assurance, 18 Resolution, and 18 SureClip) were placed in six pigs. Mucosal healing was noted at all sites on follow up. Overall retention was nine of 18 (50.0%) SureClip, 10 of 18 (55.6%) Assurance, and 13 of 18 (72.2%) Resolution ( P =0.369). There was no difference in clip retention on normal and cold snare resection sites; however, clip retention was significantly higher for Resolution clips on fibrotic ulcers (50.0% versus 0% for Assurance and 0% SureClip, P =0.03). No adverse events were reported. Ease of use was equivalent across all models. Conclusions All clips were equivalent in efficacy and safety with successful clip deployment and mucosal healing. Overall retention rate was low for fibrotic tissue, with an improved retention rate observed with Resolution clips.

S2528 Think "Inside the Loop:" A Novel Method for Repositioning a Migrated G-J Tube

Introduction: Gastrojejunostomy tube (G-J tube) migration is common in patients requiring long term percutaneous enteral feeding. These patients often present with forceful vomiting and decreased PO intake. This case discusses a method for repositioning a migrated G-J tube using an endoloop (detachable snare device) and Resolution Clips. Case Description/Methods: A 26-year-old female with a history of cystic fibrosis (CF), chronic malnutrition requiring enteral feeds, CF-related liver disease and variceal bleeding presented with 5 days of abdominal pain and coffee ground emesis. Initially, the patient was tachycardic and vomiting intermittently. Bright red blood was visible in the emesis bag. Physical exam was notable for epigastric tenderness without peritoneal signs. The skin around the G-J tube insertion site was non-tender with no signs of infection. CT of the abdomen revealed gastrosplenic varices and appropriate positioning of the enteral tube. There was no evidence of GI perforation or obstruction. An EGD demonstrated a patent gastrostomy tube in the gastric body. The jejunal tail was coiled up against the inflamed lumen of the stomach. The suture at the tip of the tail had degraded, dislodging the tube from its original position along the jejunal wall. There were blood clots in the body of the stomach but no evidence of active bleeding. Given the suspicion that the migrated feeding tube was the cause of the patient’s symptoms, a decision was made to reposition it. An endoloop was tied around the tip of the G-J tube to serve as a substitute for the suture. A cold snare was then used to secure the endoloop and drag the tail into the jejunum. The endoloop was secured to the intestinal wall using 2 Resolution Clips. The patient’s symptoms resolved after the EGD and she was discharged in stable condition (Figure). Discussion: Migration of a G-J tube is commonly associated with severe motility disorders, such as cystic fibrosis. Oftentimes, the tube will loop inside the stomach or continue toward the esophagus. The tube itself can cause gastric outlet obstruction, leading to gastric distention, nausea and vomiting. These patients are an aspiration risk and should be initially managed with IV hydration, antiemetics, and stopping of tube feeds. In addition, it is important to assess for complications such as sepsis, hemorrhage, buried bumper, or perforation of the GI tract. If the feeding tube is patent, it is reasonable to have it repositioned based on clinical judgment and provider expertise.Figure 1.: Upper Endoscopy: A. Intact gastrostomy with a patent G-J tube present in the gastric body. The jejunal tail is coiled up in the lumen of the stomach. B. The tip of the G-J tube with surrounding trauma to the body of the stomach, characterized by edema, erythema, and inflammation. The thread at the tip of the G-J tube had degraded (yellow arrow). C. An endoloop was tied at the neck of the tip of the G-J tube (black arrow) to serve as a substitute for the suture. D. A cold snare was used to secure the endoloop (black arrow) and drag the tip of the G-J tube into the jejunum. E. The endoloop (black arrow) attached to the tip of the G-J tube was secured to the wall of the jejunum using a Resolution Clip (pink arrow).

Dieulafoyʼs Lesion of Ano-Rectum: An Unusual Etiology of Lower Gastrointestinal Bleeding

Dieulafoy's lesion (DL) represents a dilated aberrant submucosal artery that erodes through the overlying mucosa in the absence of an underlying ulcer, aneurysm or intrinsic mural abnormalities. It is the culprit for 1-2% of acute gastrointestinal (GI) bleeding which in this setting could be potentially life-threatening. DL commonly occurs in stomach and rarely develops in anorectum where it could be under-recognized due to lack of proper endoscopic visualization. We report the case of a middle-aged man presenting with lower GI bleeding due to an anal DL. 59 year old male presents with recurrent painless rectal bleeding of few months duration. He reports a history of deep vein thrombosis for which he is maintained on coumadin. Vital signs were stable. Physical examination noted fresh blood in the rectal vault with no obvious external hemorrhoids. Hemoglobin level was 9 g/dL on admission with a baseline of 13 g/dL (Normal 14-18) and an International Normalized Ratio (INR) of 3.9 (Normal 0.65-1.3). Colonoscopy revealed an actively bleeding protruding vessel in the anal canal just above the pectinate line, suggestive of DL (Fig. 1). Three resolution clips were applied with full control of bleeding (Fig. 2). Rest of the colon till cecum was unremarkable. Patient had no further bleeding afterward, hemoglobin remained stable and he was discharged home 3 days later. Dieulafoy's lesion was first described in 1898 by Sir Paul Georges Dieulafoy, when he studied three young men who died of gastric hemorrhage. Since then, DL became a well-known cause of massive GI bleeding. DL occurs mainly in the upper GI tract with around 70% of lesions involving the stomach, 18% in the duodenum, 8% in the esophagus and 4% in the colorectal area. No causative factors have been determined. However, DL is mainly seen in the context of cardiovascular disease, alcohol abuse, diabetes mellitus, kidney disease and Non-Steroidal Anti-Inflammatory Drug users. Diagnosis is challenging since most lesions reside in the resulting blood pool. Moreover, DL can be overlooked if it occurs in atypical locations like in our patient. Endoscopic intervention remains the therapeutic modality of choice in almost 90% of cases while surgery is typically reserved for recurrent bleeding. Heightened awareness of anal Dieulafoy's lesions is recommended, especially that traditional diagnoses like hemorrhoids and anal fissures are almost always favored, which leads to potential misdiagnosis and worse outcome.1997_A Figure 1. Colonoscopy showing protruding vessel with active bleeding and normal surrounding mucosa suggestive of Dieulafoy's lesion1997_B Figure 2. Full control of bleeding after application of resolution clips in the anal canal.

Clipping prevents perforation in large, flat polyps.

AIMTo determine if prophylactic clipping of post-polypectomy endoscopic mucosal resection (EMR) mucosal defects of large, flat, right sided polyps prevents perforations.METHODSIRB approved review of all colonoscopies, and prospective data collection of grasp and snare EMR performed by 2 endoscopists between January 1, 2010 and March 31, 2014 in a community ambulatory endoscopy center. The study consisted of two phases. In the first phase, all right-sided, flat polyps greater than or equal to 1.2 cm in size were removed using the grasp and snare technique. Clipping was done at the discretion of the endoscopist. In the second phase, all mucosal defects were closed using resolution clips. Phase 2 of the study was powered to detect a statistically significant difference in perforation rate with 148 EMRs, if less than or equal to 2 perforations occurred.RESULTSIn phase 1 of the study, 2121 colonoscopies were performed. Seventy-five patients had 95 large polyps removed. There were 4 perforations in 95 polypectomies (4.2%). The perforations occurred in polyps ranging in size from 1.5 cm to 2.5 cm. In phase 2, there were 2464 colonoscopies performed. One hundred and sixteen patients had 151 large polyps removed, and all mucosal defects were clipped. There were no perforations (P = 0.0016). There were no post-polypectomy hemorrhages in either phase. An average of 2.15 clips were required to close the mucosal defects. The median time to perform the polypectomy and clipping was 13 min, and the median procedure duration was 40 min. Five percent of all patients undergoing colonoscopy in our community based, ambulatory endoscopy center had flat, right sided polyps greater than or equal to 1.2 cm in size.CONCLUSIONProphylactic clipping of the mucosal resection defect of large, right-sided, flat polyps reduces the incidence of perforation.

Clip retention rates and rates of residual polyp at the base of retained clips on colorectal EMR sites

Prophylactic endoscopic clipping may be effective in preventing delayed post-polypectomy hemorrhage after EMR of large colorectal lesions. The rate of retention of hemoclips on EMR sites has not been fully described. The aim of this study was to evaluate the adherence rates of hemoclips placed after EMR of large colorectal lesions. This was a retrospective review of a prospectively maintained database of large colorectal polyps (≥20mm) referred to Indiana University Hospital between June 2006 and August 2015. Sites were closed with a mean of 4 clips. Patients were followed up for 3 to 6 months after EMR with a second follow-up 1 year later. Biopsy specimens of EMR scars were examined at follow-up, including the tissue at the base of retained clips. There were 479 EMR sites in 424 patients that had first follow-up at our center with high-quality photographs of the EMR sites taken immediately after clip placement and at follow-up. Of 1407 Boston Scientific Resolution clips placed, 59 (4.2%) were retained at follow-up. Of 532 Cook Instinct clips placed, 46 (8.6%) were retained at first follow-up (P= .0001). There was no difference in the follow-up interval for the 2 clips. No patient had residual polyp by biopsy at the base of a retained clip. Clip retention at first follow-up at 3 to 6 months after EMR was twice as high for the Cook Instinct clip compared with Boston Resolution clip but retention rates were low for both clips. Residual polyp at the base of retained clips was not a significant clinical problem.

A Challenging Case of Large Gastric Polyp Removal

Figure: No Caption available.Purpose: We present a challenging case of large gastric polyp removal, performed at the Center for Advanced Endoscopy, Beth Israel Deaconess Medical Center, Boston. Results: A 75-year-old female with persistent nausea and vomiting along with abdominal pain was referred from an outside hospital on an endoscopy finding of a large gastric polyp. Past medical history was significant for hypertension, coronary artery disease, hypothyroidism and hyperlipidemia. The medications included metoprolol, lisinopril, furosemide, levothyroxine and pravastatin. We repeated an upper endoscopy at the Beth Israel Deaconess Medical Center and noticed a pedunculated polyp which appeared to be 9 cm in size and was prolapsed into the duodenum. We used a grasping forceps to pull the polyp into the stomach. We injected 4 cc of 1:10,000 epinephrine into the polyp. A 25-mm hard snare was used to resect the pedunculated polyp. The settings were zero cut and 18 coag. Three resolution clips were placed prophylactically on the base of the polyp. The resected polyp was retrieved using an endoscopic net. On patholgy, the polyp was noted to be an inflammatory fibroid polyp. The patient did well. There were no complications and there was no recurrence of the polyp one year later.

Endoscopic submucosal dissection of gastric fundus subepithelial tumors originating from the muscularis propria

Endoscopic resection of gastric subepithelial tumors (SETs) carries a high risk of perforation, particularly for tumors located at the gastric fundus and originating from the muscularis propria. Based on our experience with endoscopic submucosal dissection (ESD) and a novel endoscopic device, namely the ‘Resolution clip’ for the endoscopic closure of iatrogenic upper gastrointestinal (upper GI) perforations, we evaluated the clinical feasibility and safety of ESD for gastric fundus subepithelial tumors originating from the muscularis propria. In this prospective study, 11 consecutive patients who presented with gastric SETs ≤3 cm in diameter were enrolled. Regardless of whether perforation occurred, the gastric wall defect was closed with clips. The patients were followed up after the surgery. Endoscopic resection was successfully performed in 10 patients; however, in one patient a pure endoscopic approach was impossible as the lesion was severely adhered to surrounding tissue, and a switch to laparoscopic wedge resection was necessary. The mean resected tumor size was 18.8×17.2 mm and the mean surgery time of the 10 patients with ESD was 81 min (range 45–130 min). Histological diagnosis was gastrointestinal stromal tumor (GIST) in eight lesions [very low risk according to the National Institutes of Health (NIH) risk classification] and leiomyoma in three lesions. Perforation occurred in 3/10 patients. Gastric closure with the Resolution clips was performed successfully in all cases. Early post-ESD bleeding (EPEB) occurred in one patient. Basic ferric sulfate solution was sprayed during the upper GI endoscopy examination and the bleeding stopped. No complications occurred and the follow-up was unremarkable. In this early study, ESD using the Resolution clip was demonstrated to be a feasible and minimally invasive treatment for gastric fundus subepithelial tumors originating from the muscularis propria.

Benchtop testing and comparisons among three types of through-the-scope endoscopic clipping devices

Through-the-scope (TTS) endoscopic clipping devices are widely used. No benchtop testing or direct comparisons of these endoclips have been performed to show their rotational ability and inherent mechanical strengths during closure and after deployment. This study aimed to provide benchtop data that can be used to guide clinical applications and to promote future device research and development. Benchtop testing and comparisons were performed for three groups of TTS clips: QuickClip2 long, resolution, and instinct clips. The main outcome measurements were device-in-endoscope retroflection angles (DIERA), opening strength, "snapping" force of acute clip closure, and neoprene pulling strength. The achievable gastroscope DIERA was 10° for QuickClip2, 3° for the resolution clip, and 10° for the instinct clip. The QuickClip and the Instinct clip rotated almost equally well under all endoscope configurations, including endoscopic retrograde cholangiopancreatography (ERCP). With or without a sheath, the resolution clip lacked the ability to rotate. During clip opening force testing (the amount of force required to force open the jaws of a deployed clip by 3.2 mm; 3.2 mm was chosen due to the standard dimension of the gauge used for the measurement), the Instinct clips were the strongest. For the Instinct clips, an opening force of 404 ± 124 g was needed to open the closed clip, and an additional 386 ± 133 g was required to open the clip jaws to 3.2 mm. In terms of snapping force during acute closure and neoprene pulling strength, the instinct and resolution clips performed almost equally. The limitations of the study were the benchtop testing and the finite sample size for closing and pulling strength comparisons. The QuickClip2 and the Instinct clip rotate equally well under different endoscope configurations. The resolution clips lack rotational ability. The instinct clips are stronger mechanically than the other two TTS clips. Stronger clips are perhaps associated with higher therapeutic efficacy and retention rates.

Peroral Endoscopic Myotomy for Treating Achalasia in an Animal Model: A Feasibility Study

Background/AimsLaparoscopic Heller myotomy with antireflux procedure is considered to be a standard treatment for achalasia. Recently, peroral endoscopic myotomy (POEM) was developed and performed on patients with achalasia. However, there is no report on POEM use in South Korea. The aim of this study was to evaluate the technical feasibility of POEM in a porcine model.MethodsPOEM was performed on two mini pigs. We performed upper endoscopy under general anesthesia. A submucosal tunnel was created and the circular muscle layer was incised using several knives. The mucosal entry was closed using resolution clips. We performed a follow-up endoscopy and sacrificed the pigs 2 weeks after the POEM. The myotomy site was evaluated grossly and histologically.ResultsPOEM was successfully performed on the two mini pigs. No injuries to any abdominal or mediastinal structures occurred. Two weeks after the POEM, the esophageal mucosa healed without any endoscopic evidence of complications. Necropsy revealed that the circular muscle layer was completely lost and replaced with fibrotic tissue.ConclusionsWe found that POEM is a technically feasible method which can be performed on an animal model. However, to ensure safe use on patients with achalasia, further studies on technical methods and long-term follow-up examinations are required.

Duodenal stump fistula following Roux-en-Y gastrectomy, treated with single-balloon enteroscopy using the tulip bundle technique and fibrin glue injection

In January 2012, a 68-year-old woman underwent laparoscopic partial gastrectomy at our institute, with Roux-en-Y reconstruction for an ulcerated gastrointestinal stromal tumor. The postoperative course was complicated by development of a duodenal stump fistula and subhepatic collection (● Fig.1). Percutaneous drainage of the collection, as well as percutaneous transhepatic biliary drainage (PTBD), did not reduce the high output leakage. Because of worsening of the patient’s clinical condition, and to avoid reintervention, we decided to carry out single-balloon enteroscopy to access the afferent loop and reach the duodenal stump. Informed consent was obtained from the patient. Single-balloon enteroscopy was carried out with a high resolution enteroscope (SIF-Q180; Olympus America, Center Valley, Pennsylvania, USA) and a disposable sliding overtube (ST-SB1; Olympus America). There was a large, 2-cm orifice surrounded by hyperemic mucosa at the duodenal stump (● Fig.2). To apply the tulip bundle technique [1,2], eight Resolution Clips (Boston Scientific, Natick, Massachusetts, USA) were placed circumferentially along the periphery of the fistula, and two Endoloops (Olympus America) were placed over the endoclips, near the base, to fully close the fistula (● Fig.3a– c). We then injected 4mL of fibrin glue (Beriplast-P Combi-Set; CSL Behring, Marburg, Germany) into the submucosa to ensure complete sealing of the fistula (● Fig.3d– f). Definitive fistula closure was clinically and radiologically observed at the 2 months’ follow-up (● Fig.4). Duodenal stump fistula after gastrectomy is a potentially devastating complication, with high morbidity, long period of hospitalization, and an overall mortality rate of about 20% (due to sepsis and multiple organ failure) [3]. Treatment with PTBD and an occlusion balloon in the biliary tree has been described [4,5]. This report describes a new endoscopic treatment for a refractory duodenal stump fistula and illustrates the feasibility and usefulness of interventional single-balloon enteroscopy. In conclusion, we believe that in the case of a life-threatening complication in the small intestine which is difficult to access, single-balloon enteroscopy may be a viable alternative to surgical intervention.

Su1481 Large Sessile Colorectal Polyps: Reduction in Delayed Bleeding With Prophylactic Clipping

Resection of large (≥ 2cm) sessile colorectal polyps is associated with an increased risk of complications. We performed a retrospective assessment of the impact of prophylactic closure of polypectomy sites using Microvasive Resolution clips. There were 537 sessile colorectal polyps ≥ 2cm in size removed from 482 patients. We successfully completed follow up for complications by telephone after 30 days for 474 polyps. Mean age of the 420 patients with complete follow up was 67.4 years, mean polyp size 32.3mm, and 253 polyps were ≥ 3cm in size.

Assessment of a simple, novel endoluminal method for gastrotomy closure in NOTES

A reliable method for gastrotomy closure in NOTES will be essential for NOTES to become viable clinically. However, methods using existing and widely available endoscopic accessories have been ineffective. The objective of this study was to evaluate the feasibility and safety of a new simple method for gastric closure (retracted clip-assisted loop closure) that uses existing endoscopic accessories with minor modifications. The retracted clip-assisted loop closure technique involves deploying 3-4 Resolution(®) clips (modified by attaching a 90-cm length of suture to the end of each clip) along the margin of the gastrotomy with one jaw on the serosal surface and the other jaw on the mucosal surface. The suture strings are threaded through an endoloop. Traction is then applied to the strings causing the gastric wall to tent. The endoloop is secured below the tip of the clips, completing a full-thickness gastrotomy closure. The main outcome measures were feasibility, efficacy, and safety of the new retracted clip-assisted loop closure technique for NOTES gastrotomy closure. An air-tight seal was achieved in 100% (n = 9) of stomachs. The mean leak pressure was 116.3 (±19.4) mmHg. The retracted clip-assisted loop closure technique can be used to perform NOTES gastrotomy closure by using existing endoscopic accessories with minor modifications.

Endoscopic closure of a rectovaginal fistula combiningN-2-butyl-cyanoacrylate (Histoacryl) and Resolution clips

communications between the anterior wall of the rectum and the posterior vaginal wall. The incidence of RVFs is relatively low; most of them are related to obstetric injury [1]. Patients complain of uncontrollable passage of gas or feces from the vagina. RVFs may be managed both medically and surgically. Endoscopic approaches with endoclip closure of gastrointestinal fistula and injection of tissue adhesive have been proposed [2], but a combined approach using both methods has not been described. We present a case of a RVF successfully treated endoscopically with N-2-butyl-cyanoacrylate (Histoacryl; B. Braun, Melsungen, Germany) and Resolution clips (Microvasive Endoscopy, Boston Scientific Corp., Natick, Massachusetts, USA). A 78-year-old woman with a diagnosis of acute myeloid leukemia complained of passing stool and gas from the vagina. Having rejected surgery, she was referred to our unit, where sigmoidoscopy showed a 6-mm orifice in the anterior wall of the rectum (● Fig. 1). Three Resolution clips were placed in order to appose the margins (● Fig. 2), and a 1:1 mixture (2ml) of Histoacryl and lipiodol was injected into the internal opening and fistulous tract (● Figs. 3 and 4). The patient had early relief of her complaints and remained asymptomatic 2 months after the procedure. Cyanoacrylates are a class of synthetic glues that rapidly solidify upon contact with body fluids. Histoacryl is the most commonly used cyanoacrylate glue for gastrointestinal applications. It has shown to be successful in the closure of pancreatic [3] , biliary [4], and gastrointestinal fistulas [5] in patients in whom conservative treatment has failed as well as in surgically high-risk patients. Mixing Histoacryl with lipiodol retards polymerization. In our experience, a combined approach using Resolution clips and Histoacryl may improve the rate of technical success in the endoscopic treatment of RVFs, since clips not only work in apposing the margins, but act as a scaffold for the glue. Endoscopic closure of a rectovaginal fistula combining N-2-butyl-cyanoacrylate (Histoacryl) and Resolution clips

Endoscopic Management of Colo-Cutaneous Fistula Masquerading as Unexplained Diarrhea and Malabsorption

Purpose: 82-year old woman with dysphagia secondary to stroke, who underwent placement of a percutaneous endoscopic gastrostomy (PEG) 6 months earlier presented with chronic diarrhea. On exam, the external bolster of the PEG was only 2 cm outside the skin, suggesting migration of the PEG, with a freely mobile and functioning tube. Laboratory data revealed severe hypokalemia and hypomagnesaemia due to chronic diarrhea and malnutrition. CT scan showed PEG tube located in distal parts of the transverse colon. EGD confirmed healing and closure of the gastric site of PEG. On colonoscopy, the bumper of the PEG was located in transverse colon. The tip of the PEG tube at skin level was severed and the bumper was snared and retrieved out from colon. Four Resolution ® endoclips were deployed to close the colonic defect (Figure A). Antibiotics were administered for 48 hours. No leak was reported, and patient's diarrhea resolved. A new PEG was inserted uneventfully 7 days later.Figure A: Closed fistula after endoclips placement.Discussion: The practice of PEG placement had revolutionized the delivery of human nutrition in certain clinical settings. While this is a relatively safe procedure, complications may rarely occur such as tube migration. This is suspected when the external part of the tube is pulled into the abdominal cavity. Enterocutaneous fistulae are direct complications of tube migration. Gastro-cutaneous fistula is a rare sequel following the removal of the PEG. Colocutaneous fistula, on the other hand, is an extremely rare complication of PEG placement, yet the management can be quite challenging. Our case illustrates an unusual presentation of PEG migration as chronic diarrhea and malabsorption, primarily due to small bowel bypass. Successful endoscopic extraction of the PEG tube from colon and closure of the fistula tract with resolution clips promptly restored the continuity of the bowel and reversed the pathophysiological derangement. Conclusion: We presented a case of colo-cutaneous fistula, a rare and unusual complication of PEG placement, with successful endoscopic retrieval of the migrated PEG tube and closure of the colonic defect utilizing endoclipping technique.

Case report of a hemostatic clip being retained for 2 years after deployment

The use of hemostatic clips in upper GI bleeding is a common mode of interventional therapy used by endoscopists worldwide. There exist strong data which advocates the use of dual intervention (either hemostatic clips or thermocoagulation together with injection) when faced with a bleeding ulcer compared with monotherapy with injections. 1 Laine L. McQuaid K.R. Endoscopic therapy for bleeding ulcers: an evidence-based approach based on meta-analyses of randomized controlled trials. Clin Gastroenterol Hepatol. 2009; 7: 33-47 Abstract Full Text Full Text PDF PubMed Scopus (243) Google Scholar , 2 Barkun A.N. Martel M. Toubouti Y. et al. Endoscopic hemostasis in peptic ulcer bleeding for patients with high-risk lesions: a series of meta-analyses. Gastrointest Endosc. 2009; 69: 786-799 Abstract Full Text Full Text PDF PubMed Scopus (159) Google Scholar , 3 Conway J.D. Adler D.G. et al. ASGE Technology CommitteeEndoscopic hemostatic devices. Gastrointest Endosc. 2009; 69: 987-996 Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholar , 4 Chuttani R. Barkun A. et al. Technology Assessment CommitteeEndoscopic clip application devices. Gastrointest Endosc. 2006; 63: 746-750 Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar Prolonged endoclip retention timeGastrointestinal EndoscopyVol. 74Issue 3PreviewIn response to an article published in December 2010 titled “Case report of a hemostatic clip being retained for 2 years after deployment,”1 we want to report that we have had similar experience in our outpatient gastroenterology office. In 2008, we performed a retrospective chart review study for which data were collected from 22 patients who had clips placed between April 2007 and April 2008. In 20 of these patients, Resolution clips (Boston Scientific Corp., Natick, Mass) were used to achieve hemostasis, whereas Olympus clips (Olympus America Inc., Center Valley, PA) were used in the other 2 patients. Full-Text PDF

Endoscopic resection of very large submucosal tumors in the colon is feasible

Introduction: Submucosal tumors of the colon are rare and usually incidental findings causing no symptoms. Lesions bigger than 2cm are usually resected surgically if the cause symptoms as endoscopic resection is associated with an elevated risk for perforation. Patient and Method: We report on a 57 year old patient who underwent colonoscopy because of recurrent abdominal pain, intermittent constipation and a positive fecal occult blood test. A large submucosal tumor with a short stalk was found in the ascending colon. Because of the symptoms and the size of the lesion the patient was scheduled for surgery. Due to concomitant diseases like COPD Gold III, hypertension and massive obesity the patient was regarded as high risk and colonoscopic resection with surgical stand-by was planned. Because of the huge size, placement of an Endo-Loop® (Olympus Corp.) was not possible. The tumor was therefore resected using a Jumbo Captivator Snare® (Boston Scientific). The area of resection was closed using six Resolution Clips® (Boston Scientific). No complication occurred and the patient was discharged the next day. Results: The resected specimen measured 5.5cm in diameter. Histopathological work-up revealed a lipoma, resected completely and in one piece. Discussion: Only five cases of endoscopic resection of submucosal tumors measuring 5cm or more in diameter have been published so far. Perforation occurred once in a sessile lesion. Endoscopic removal of very large submucosal tumors is feasible and seems to be reasonably save even without prior placement of an Endo-Loop®. However, interdisciplinary management of such cases is mandatory in order to maximize patient's safety and to deal with potential complications like perforation or hemorrhage. Endoscopic resection of very large submucosal tumors seems to be a viable treatment option for symptomatic patients unfit for surgery.

Technologies Employed to Control Access to or Use of Digital Cultural Collections

This article describes the results of a survey investigating the use of technological protection measure (TPM) tools to control patron access to or use of digital cultural materials made accessible by U.S. archives, libraries and museums. Libraries reported using a broader range of systems than archives or museums including repository software, streaming media servers, digital library software and courseware. In terms of controlling access to collections, most respondents reported using IP range restrictions and network-ID based authorization systems. Some reported restricting access to approved terminals or individual user registration systems. In terms of controlling use of collection items, respondents reported reliance on resolution limits, clips and thumbnails, and visible watermarking. A lower percentage reported use of click-through license agreements. Few institutions reported using new technologies to control access or use such as pop-ups, disabling right click copy and save functionalities, invisible watermarks, viewers or cross-institutional authentication systems.

Endoscopic resection of rectal gastrointestinal stromal tumor (GIST) using band ligation

A 52 year-old male patient was referred for endoscopic resection of a 10 x 6-mm hypoechoic lesion on the anterior wall of the distal rectum. It derived from the “muscularis propria”, and was deemed to be a gastrointestinal stromal tumor (GIST) from its characteristic appearance and localization as shown during endoscopic ultrasonography (EUS) (Fig. 1). An extension study proved negative. Band ligation was chosen for resection. Firstly, the tissue over the lesion was vacuumed with one band, and then a cut was performed under the band using a detachable snare. Thus, the lesion was thoroughly exposed. Afterwards, the lesion was vacuumed and a second band was placed. A new cut below the band was performed (Fig. 2), which dissected the lesion producing a perforation on the rectal wall that was sutured with Resolution clips (Boston Scientific, Natick, Mass). No further complications took place. The patient needed neither hospitalization nor prescribed antibiotics. Pathology confirmed the suspected tumor type. After six months an axial computerized tomogram (CT scan) and a EUS procedure showed no evidence of lesion relapse (Fig. 3).

When Temporary Clips Linger

Purpose: Endoscopic clips are designed to be temporary devices in the achievement of hemostasis. Having stopped the acute bleeding, they usually dislodge and pass through the gastrointestinal tract. Studies have looked at early clip dislodgement resulting in rebleeding and this appears to be rare. Whether clips can be retained for long periods of time (e.g. months) is unclear. We report here two patients who had clips retained for five to six months, one in the upper GI tract and the other in the lower GI tract. Patient 1 is a 47-year-old man who presented to WVUH with abdominal pain, nausea, and multiple episodes of hematemesis. On EGD he had a large visible vessel in the cardia just below the GE junction actively oozing fresh blood. Epinephrine was injected into the area and 2 clips (Boston Scientific Resolution clips) were deployed on the vessel. The patient did well and was discharged to home three days later. Six months after his initial presentation, he again presented to the hospital with nausea, vomiting, and abdominal pain. He denied hematemesis. An upper endoscopy revealed erosive gastritis and one retained clip. His symptoms improved with carafate and esomeprazole and he was discharged soon after. Patient 2 is a 64-year-old man with significant lower GI bleed. A colonoscopy revealed multiple polyps, pandiverticulosis and a visible vessel was found in a diverticulum, for which clips were deployed. The patient presented five months later to clinic complaining of intermittent streaks of dark blood in his stools. A repeat colonoscopy seven months after the clip was initially deployed revealed the clip was still present in the right colon. Although neither patients' symptoms were likely secondary to the retained clips, we report two cases of temporary clips remaining in place for several months. Review of the literature suggests that different clips remain attached for different periods of time. For example, in a study by Jensen et. al. Triclips fell off significantly faster than Resolution Clip or QuickClip2 and the Resolution Clips were retained significantly longer than the other two clips. Thus, while it appears that retained surgical clips did not lead to adverse effects in patients, it appears that different brands of clips carry different retention times, and caution should be used in applying clips to sites that are intended to be temporary.

Successful Endoscopic Closure of a Gastro-Gastric Fistula with Endo-Clips

Purpose: Roux-en-Y gastric bypass (RYGBP) is a mainstay of bariatric surgical therapy. A Gastro-Gastric Fistula (GGF) is an infrequent but potentially serious complication of gastric bypass, and clinicians often have difficulty establishing the diagnosis. We report a novel endoscopic technique of successful management of GGF using APC and endo-clips. Methods: A 31-year-old woman with a BMI of 44 underwent a laparoscopic divided ante-colic Roux-en-Y gastric bypass (RYGBP), with creation of a 30-cc gastric pouch. Her immediate post-operative course was unremarkable. She was discharged home on the 6th post-operative day. Two months later, she complained of persistent postprandial nausea and emesis. An upper GI series performed revealed a GGF, with preferential flow into the bypassed stomach (Fig. 1). Despite this finding, she has achieved a 70% excess weight loss. The patient had elected not to pursue revisional surgery. Upper Endoscopy was performed. No marginal ulcerations noted. GGF was identified at the cardia. Twice daily PPI's did not improve her symptoms. Two weeks later repeat endoscopy was perfomed. A guide-wire was passed through the fistula. Fluoroscopy confirmed the position of the cannula in the distal stomach pouch. APC of the fistula tract was done. Two Boston Scientific Resolution Clips were used to close the fistula after APC of the tract. The patient was sent home on twice daily PPI. Her symptoms improved. Repeat upper GI series three weeks later showed closure of GGF (Fig. 2). Results: Although a gastro-gastric fistula is currently an uncommon complication of RYGBP, historically GGF was one of the most common complications after undivided RYGBP, occurring in up to 50% of patients. This complication rapidly declined with the introduction of laparoscopic gastric bypass with an incidence ranging from 0–6%. Multiple factors likely to play a role in the formation of a GGF. Failure to completely transect the gastric pouch from the bypassed stomach, gastrojejunal anastomotic leak, anastomotic or marginal ulcerations, and obstruction of the Roux-limb distal to the anastomosis is few of the causes of formation of GGF. In patients with a clearly identifiable GGF on contrast study and/or endoscopy who demonstrate poor weight loss, revisional surgery should be considered. In patients with demonstrable GGF but good weight loss, PPI therapy should be used to treat symptoms. Conclusion: In symptomatic patients, as we have shown, obliterating the fistula tract using APC and closure of GGF using endo-clips should be considered safe and effective.