Successful Endoscopic Closure Research Articles

Ring-string traction for successful endoscopic clip closure to treat delayed perforation of the ulcer bed after colorectal endoscopic submucosal dissection.

Ring-string traction for successful endoscopic clip closure to treat delayed perforation of the ulcer bed after colorectal endoscopic submucosal dissection.

Esophagogastric anastomotic leakage and anastomotic fistula: what can we do when endoluminal vacuum therapy fails?

Anastomotic leak and anastomotic fistula after esophagectomy are frequent and detrimental complications after esophagectomy. Endoluminal vacuum therapy has been used as alternative treatment for these type of complications refractory to use of lumen-apposing metal stents and other endoscopic modalities. In this report, we describe successful endoscopic closure of anastomotic leak and anastomotic fistula with fibrin sealant as adjuvant therapy after vacuum therapy failed to completely treat these complications.

S3363 Successful Endoscopic Closure of an Iatrogenic Hypopharyngeal Perforation Using MANTIS Clips

S3363 Successful Endoscopic Closure of an Iatrogenic Hypopharyngeal Perforation Using MANTIS Clips

Successful endoscopic closure of a large esophageal perforation using the purse-string technique.

Successful endoscopic closure of a large esophageal perforation using the purse-string technique.

Successful Endoscopic Closure of the Appendiceal Orifice

Introduction: Colocutaneous fistulas are severe complications that traditionally are repaired surgically with resection of the fistula followed by end-to-end anastomosis of the bowel. Given the high morbidity of surgery, an alternative approach to consider is endoscopic fistula closure with clips, which is a minimally invasive approach and is safe with high success rates.1–5 Currently, there are no reports in the literature describing endoscopic closure of the appendiceal orifice. This video case report describes a technique for placement of an over the endoscope clip at the appendiceal orifice to effectively close a colocutaneous fistula. Materials and Methods: The patient was a 69-year-old male with Marfan's syndrome who was 5 months status post primary repair of a duodenal perforation with feculent peritonitis. His early postoperative course was complicated by a persistent leak from an unknown source. One month postoperatively, imaging showed a large retroperitoneal abscess that required percutaneous drain placement. At that time, surgical endoscopy was consulted for duodenal evaluation and found no clear evidence of a leak from the duodenum. A percutaneous endoscopic gastrostomy tube with a jejunal feeding extension was placed. Four months after his index operation, he presented to the clinic with a change in drain output character that was suspicious for an enterocutaneous fistula. Fistulogram with contrast injected into the patient's percutaneous drainage catheter demonstrated continuity with the colon in the right lower quadrant. He was taken for a colonoscopy and fluoroscopy for further evaluation of the colocutaneous fistula. After injection of saline at the drain site, saline was seen trickling into the cecum from the appendiceal orifice. The decision was made to close the orifice with a 12/6T over-the-endoscope clip. The percutaneous retroperitoneal drain was removed 5 days postoperatively and he was discharged home 7 days postoperatively on a low residue diet. Results: At 1 month follow-up, the patient was doing well on a regular diet with no abdominal pain or fevers. A routine imaging scan performed 7 weeks postoperatively showed no recurrent retroperitoneal fluid collection. His gastrojejunal feeding tube was removed. Conclusion: Over-the-endoscope clipping of the appendiceal orifice to repair a colocutaneous fistula is technically feasible and appears safe. Endoscopic therapy spared this patient from a potential ileocecectomy. To date, no other similar procedures have been performed by our department in other patients. Further study is necessary to establish the safety of this procedure before its implementation as standard practice. A.H. has no disclosures. E.M.P. is a lecturer for BD, Medtronic, Ovesco, and Boston Scientific. E.M.P. is a consultant for Boston Scientific, Actuated Biomedical, Baxter, Wells Fargo, Cook Biotech, Neptune Medical, Surgimatrix, CMR Surgical, Boehringer Laboratories, Allergan, and Noah Medical. J.S.W. is a consultant for Boston Scientific. Author(s) have received and archived patient consent for video recording/publication in advance of video recording of procedure. Runtime of video: 5 mins 20 secs This video was accepted as a video presentation at the 2023 Society of Gastrointestinal and Endoscopic Surgery on March 29 to April 1, 2023.

A120 ENDOSCOPIC CLOSURE TECHNIQUES FOLLOWING ACUTE IATROGENIC PERFORATION -- AN UPDATED SYSTEMATIC REVIEW

Abstract Background Iatrogenic perforation is arguably the most feared adverse event associated with endoscopy. Current American Society for Gastrointestinal Endoscopy (ASGE) and European Society of Gastroenterology Endoscopy (ESGE) guidelines recommend endoscopic closure as the first-line treatment strategy. Historically, this has been achieved using through-the-scope clips (TTSC). Given the emergence of alternative endoscopic closure techniques including over-the-scope clips (OTSC) and endoscopic suturing, we sought to provide an updated review of the literature. Purpose To review endoscopic closure techniques following iatrogenic perforation during screening or therapeutic endoscopy. Method Based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Guidelines, an electronic search of MEDLINE and EMBASE from June 1st, 1946 – Oct 10th, 2022 was performed. Inclusion criteria was limited to English full-text original citations, with case reports, and cohorts with < 3 patients excluded. Our primary objective was to assess complete defect closure after attempted endoscopic treatment. Outcomes were stratified by modality (TTSC, OTSC, endoscopic suturing) and chronologically based on a previous well received systematic review. Result(s) A total of 2549 citations were identified in our electronic search, of which 34 were included representing 830 perforations. Overall, successful endoscopic closure was achieved in 763 cases (91.9%). When stratified by endoscopic closure techniques, range estimates for successful endoscopic closure was 71% – 100%, 57% - 100%, and 100% for TTSC, OTSC and endoscopic suturing respectively. When stratifying chronologically, an improvement in TTSC closure was identified. Conclusion(s) Endoscopic defect closure, including TTSC, OTSC and endoscopic suturing, are effective in the management of iatrogenic perforations with increasing TTSC performance over time. It remains the primary treatment strategy for iatrogenic perforation. Please acknowledge all funding agencies by checking the applicable boxes below None Disclosure of Interest None Declared

Adverse events of endoscopic full-thickness resection: results from the German and Dutch nationwide colorectal FTRD registry

Endoscopic full-thickness resection (eFTR) is emerging as a minimally invasive alternative to surgery for complex colorectal lesions. Previous studies have demonstrated favorable safety results; however, large studies representing a generalizable estimation of adverse events (AEs) are lacking. Our aim was to provide further insight in AEs after eFTR. Data from all registered eFTR procedures in the German and Dutch colorectal full-thickness resection device registries between July 2015 and March 2021 were collected. Safety outcomes included immediate and late AEs. Of 1892 procedures, the overall AE rate was 11.3% (213/1892). No AE-related mortality occurred. Perforations occurred in 2.5% (47/1892) of all AEs, 57.4% (27/47) of immediate AEs, and 42.6% (20/47) of delayed AEs. Successful endoscopic closure was achieved in 29.8% of cases (13 immediate and 1 delayed), and antibiotic treatment was sufficient in 4.3% (2 delayed). The appendicitis rate for appendiceal lesions was 9.9% (13/131), and 46.2% (6/13) could be treated conservatively. The severe AE rate requiring surgery was 2.2% (42/1892), including delayed perforations in .9% (17/1892) and immediate perforations in .7% (13/1892). Delayed perforations occurred between days 1 and 10 (median, 2) after eFTR, and 58.8% (10/17) were located on the left side. Other severe AEs were appendicitis (.4%, 7/1892), luminal stenosis (.1%, 2/1892), delayed bleeding (.1%, 1/1892), pain after eFTR close to the dentate line (.1%, 1/1892), and grasper entrapment in the clip (.1%, 1/1892). Colorectal eFTR is a safe procedure with a low risk for severe AEs in everyday practice and without AE-related mortality. These results further support the position of eFTR as an established minimally invasive technique for complex colorectal lesions.

Successful Endoscopic Closure of Gastrobronchial Fistula Using Polyglycolic Acid Sheets with Fibrin Glue

Successful Endoscopic Closure of Gastrobronchial Fistula Using Polyglycolic Acid Sheets with Fibrin Glue

S2280 Benign Bronchoesophageal Fistula Recalcitrant to Endoscopic Management

Introduction: The management of bronchoesophageal fistulas (BEFs) can be challenging and often requires a multidisciplinary approach. We present the case of a spontaneous BEF that defied multiple endoscopic attempts at closure. Case Description/Methods: A 69-year-old malnourished woman with heavy tobacco use and chronic obstructive pulmonary disease presented with cough incited by food intake and pneumonia. Fluoroscopic contrast study highlighted a bronchoesophageal fistula with opacification of the left mainstem bronchus (Figure). An initial upper endoscopy demonstrated a small recess but without an obvious fistulous opening at 29 cm from the incisors and without malignancy on biopsy. A subcarinal 2.3 cm broncholith seen on a chest CT performed 2 years prior was now noticeably absent, suggesting broncholith erosion as the cause of the BEF. An attempt at endoscopic closure was recommended by multidisciplinary consensus. Since the fistulous opening was not readily identifiable at initial endoscopy, a combined bronchoscopic-endoscopic procedure was performed with bronchoscopic passage of a guidewire through the fistula tract into the esophagus. Once localized, abrasion of the fistula orifice with argon plasma coagulation followed by over-the-scope clip (OTSC) closure was performed. Symptom and radiographic recurrence at 2 weeks from migration of the OTSC resulted in uneventful endoscopic removal of the OTSC. Subsequent placement of a fully covered self-expandable metal stent with endoscopic suture fixation resulted in intolerable chest pain despite narcotic administration and incomplete sealing of the fistula on radiographic imaging, necessitating stent removal one week later. A third attempt at endoscopic suture closure of the fistula was unsuccessful. A PEG-J feeding tube was placed for enteral nutrition as well as a retrograde pigtail drainage catheter fitted through the PEG to manage secretions at and above the BEF. Definitive surgical repair will be considered once her nutritional status is optimized. Discussion: Despite publications of successful endoscopic closure of benign BEFs, a significant proportion of these cases do not respond to endoscopic interventions and are not likely to be reported in the literature (reporting bias). Benign BEFs should be managed in a multidisciplinary fashion and alternative treatment strategies pursued when endoscopic therapies are deemed unsuitable or fail at closing the fistula.Figure 1.: Esophagram highlighting bronchoesophageal fistula. Esophagus (blue arrows); left mainstem bronchi (red arrows).

S2797 Closing the Gap: First Report of Endoscopic Suture Closure of Malignant Gastric Hemorrhage

Introduction: Gastrointestinal bleeding secondary to luminal malignancy is typically difficult to manage with conventional endoscopic therapies. Endoscopic suturing devices have become increasing popular for the management of various resection defects, inadvertent perforations, and bariatric endosurgery. Limited recent data suggests that this technology is effective for refractory bleeding from benign peptic ulcer disease. Herein we describe a case of the successful endoscopic closure of a bleeding malignant gastric ulcer using endoscopic suturing. Case Description/Methods: A 60-year-old male with a past history of primary thrombocytopenia, and recent diagnosis of signet ring gastric adenocarcinoma/linitis plastica (T2, N2, M0) on FLOT chemotherapy (5-fluorouracil, leucovorin, oxaliplatin, and docetaxel) presented with hematemesis and acute on chronic anemia. Physician examination was notable for tachycardia and hypotension. Laboratory evaluation was notable for a hemoglobin of 7.8 g/dL from 15.0 g/dL four days prior. The patient was intubated and urgent upper endoscopy in the intensive care unit was performed which showed active oozing and bleeding from a cratered gastric ulcer (previously biopsy proven adenocarcinoma) on the proximal lesser curvature measuring approximately 20 mm in size (A). Diffuse thickening of gastric folds consistent with linitis plastica was also seen. Initial attempts with bipolar cautery and epinephrine injection were unable to achieve hemostasis. An endoscopic suturing system was employed to place a suture in a figure of eight fashion and cinched at end with closure of the ulcer bed (B). The ulcer bed was not visible after suturing and hemostasis was achieved (C). Repeat upper endoscopy after two weeks for nasojejunal feeding tube placement did not show presence of ulcer and any recurrent bleeding. Patient is being clinically optimized to resume chemotherapy. Discussion: To our knowledge, we describe herein the first case of successful use of endoscopic suturing for closure of a bleeding malignant gastric ulcer. We hypothesize that the thickened gastric folds secondary to the histologic nature of linitis plastica allowed for adequate tissue purchase at the margins of the bleeding gastric ulcer which would typically be precluded in malignant tissue due to its friable nature.Figure 1.: A: Endoscopic image of gastric adenocarcinoma and associated cratered ulcer with oozing hemorrhage. B: Endoscopic image of suture device during closure. C: Endoscopic image of successful approximating edges of ulcer after endoscopic suturing without evidence of bleeding.

TU1.12 Video Presentation: The OVESCO Clip for Endoscopic Treatment of Gastrocutanoeus Fistula

Abstract Background Percutaneous endoscopic gastrostomy (PEG) is an important route of nutrition in many patients. PEG removal usually leads to spontaneous closure in a few days. Gastrocutaneous fistula (GCF) after PEG removal is an uncommon complication occurring in 2% of patients. Despite its rarity, it is responsible for significant morbidity and reduced quality of life. Treatment is initially focused on medical management and endoscopic clipping, with advanced endoscopic techniques and surgery reserved for selected cases. Method We present a video presentation demonstrating successful endoscopic treatment of GCF using the OVESCO Over the Scope clip with resolution of symptoms and closure of the fistula tract. The device is a novel innovation designed to achieve tissue apposition and compression without ischaemia. It is licensed for Gastrointestinal iatrogenic defects, endoscopic perforation, bleeding and GCF. The 72 year old patient had debilitating symptoms of gastric leakage for over a year despite previous attempts at endoscopic clipping, fibrin glue and curettage of the fistula tract. Results As shown in the video, the clip achieved good opposition with no post procedural leak. The patient was reviewed at 3 and 12 months with no recurrence of their symptoms. The external cutaneous opening had closed at 3 months. The patient reported an increase in weight, improved mood and a greater quality of life following the intervention. Conclusion The OVESCO clip has been proven to facilitate successful endoscopic closure of GCF in selected patients in whom initial treatment measures have failed. This mitigates the need and risks of surgical closure.

Successful endoscopic closure with an over-the-scope clip for sigmoid colon perforation due to bile duct stent migration

An 86-year-old woman presented with a history of endoscopic papillary sphincterotomy for bile duct stones and diverticulitis. The patient was admitted as an emergency case of acute cholangitis due to choledocholithiasis, underwent endoscopic bile duct stenting, and was discharged with a plan for endoscopic lithotripsy. One month later, the patient was readmitted owing to abdominal pain. Abdominal computed tomography at admission showed that the bile duct stent had migrated to the sigmoid colon and the presence of a small amount of extraintestinal gas, suggesting a colonic perforation. Lower gastrointestinal endoscopy showed adhesions and intestinal stenosis in the sigmoid colon, probably after diverticulitis, and the bile duct stent that had perforated the same site. The stent was removed and endoscopic closure of the perforation was performed using an over-the-scope clip. Abdominal computed tomography 8 days after the closure showed no extraintestinal gas. The patient resumed eating and was discharged on the 14th day of admission. There was no recurrence of abdominal pain. Endoscopic closure of sigmoid colon perforation due to bile duct stent migration using an over-the-scope clip has not been reported thus far, and it may be a new treatment option in the future.

Successful endoscopic closure with endoscopic clips for endoscopic ultrasound related large duodenal perforation.

Objectives: Duodenal perforation as a complication of endoscopic ultrasound-guided fine needle aspiration may progress to acute peritonitis and septic shock. Open surgery, the standard treatment, can be avoided by performing closure during endoscopy using endoscopic clips.Patient: A 77-year-old woman was referred to our hospital with salivary gland swelling. She had elevated hepatobiliary enzymes and jaundice. Computed tomography (CT) revealed pancreatic head swelling and bile duct dilation. Endoscopic ultrasonography revealed a hypoechoic mass in the pancreatic head. The pancreatic head mass was punctured twice using a 22-gauge Franchine-type puncture needle at the duodenal bulb. The endoscope was advanced to the descending part of the duodenum, and part of the superior duodenal angle was perforated (diameter approximately 15 mm) with the endoscope. The duodenal mucosa around the perforation was immediately closed using endoscopic clips.Results: Abdominal CT showed gas in the peritoneal and retroperitoneal spaces. The patient experienced abdominal pain and fever and was treated with fasting and antibiotics. The gas gradually decreased, symptoms improved, and she was discharged 18 days after the perforation. Histopathologically, the pancreatic tissue was consistent as autoimmune pancreatitis.Conclusion: Endoscopic closure using endoscopic clips may be a better therapeutic option for duodenal perforation caused by endoscopy.

914 Dissection-Enabled Scaffold-Assisted Resection (DeSCAR): A Novel Technique for Resection of Residual or Non-Lifting GI Neoplasia of the Colon, Expanded Experience and Follow-Up

INTRODUCTION: Colonic lesions referred for endoscopic mucosal resection (EMR) may not be amenable to conventional snare resection due to previous manipulation or submucosal invasion or because of flat lesions unable to be snared. In 2018, we initially described Dissection-enabled Scaffold Assisted Resection (DeSCAR)—a combination of circumferential endoscopic submucosal dissection (ESD) with EMR—to be safe for the endoscopic resection for removal of non-lifting or residual colonic lesions with suspected submucosal involvement or fibrosis. We describe our expanded experience and follow up of patients undergoing DeSCAR and assess the efficacy, safety, and feasibility of DeSCAR for endoscopic resection of non-lifting or residual colonic lesions. METHODS: Lesions referred for EMR were retrospectively reviewed. Our initial cohort of 29 patients from 2015-2017 combined with 28 additional patients from 2018-2019 were identified where the DeSCAR technique was performed for colonic lesions with incomplete lifting and/or snaring. Cases were reviewed for location, prior manipulation, rates of successful hybrid resection, adverse events, and endoscopic follow up to assess for residual lesions. RESULTS: 57 lesions underwent DeSCAR for non-lifting or residual colonic lesions. Patients were 51% female and 49% male with an average age 69 (SD +/- 9.6 yrs). Lesions were located in the cecum (n = 16), right colon (n = 22), transverse colon (n = 5), left colon (n = 7), rectum (n = 4), or in other locations defined by distance from the anus (n = 4). Average lesion size was 27.7 mm (SD +/- 16.6 mm). Previous manipulation occurred in 54 of 57 cases (68% biopsy, 47% resection attempt, 18% intralesional tattoo). The technical success rate for resection of non-lifting lesions was 100%. There were two delayed bleeding episodes (one required endoscopic intervention) and one small perforation (managed by successful endoscopic hemoclip closure at the time of perforation). No other adverse events were observed. Endoscopic follow up was available in 27 patients (47%) with no residual adenoma noted in 25 patients (93% of those with surveillance). CONCLUSION: Our expanded experience with DeSCAR continues to demonstrate a high safety, feasibility, and effectiveness profile for the endoscopic management of non-lifting or residual colonic lesions, providing en-bloc resection of tissue for histologic review. Further studies are needed to demonstrate long-term eradication and direct comparison with other currently available endoscopic techniques.

1889 Endoscopic Closure of Gastrocolic Fistula Using Hemostatic Clips: A Novel Approach

INTRODUCTION: Traditionally, surgery is the mainstay of treatment for gastrointestinal fistulas; more recently, however, therapeutic endoscopic stent placement is being explored for high-risk patients. Successful endoscopic closure of these fistulas using hemostatic clips offers the possibility of an alternative, viable approach for patients who are nonsurgical candidates and may benefit from noninvasive endoscopic interventions. CASE DESCRIPTION/METHODS: An 82-year-old male with history of peptic ulcer disease, alcohol abuse, and Billroth II gastrojejunostomy >20 years ago was admitted due to bloody diarrhea. Physical examination was unremarkable except for melena. Laboratory testing revealed a hemoglobin level of 4.6g/dL. After resuscitation, upper endoscopy was performed and the patient was found to have a mucosal perforation at the anastomotic site with an adjacent clean-based ulcer (A, B) without active bleeding. The mucosal defect was closed using four hemostatic clips (C). Abdominal CT scan later confirmed a gastrocolic fistula successfully closed with clip placement (D). The patient’s symptoms resolved; his remaining hospital course was uncomplicated. DISCUSSION: Intervention during endoscopy precluded the need for surgical intervention in an elderly patient who would otherwise have been a poor surgical candidate. To the best of our knowledge, this is the first use of hemostatic clip placement for closure of a gastrocolic fistula.

Successful endoscopic closure of an esophageal leak after endoscopic ultrasound-guided hepaticoesophagostomy by using n-butyl-2 cyanoacrylate

Successful endoscopic closure of an esophageal leak after endoscopic ultrasound-guided hepaticoesophagostomy by using n-butyl-2 cyanoacrylate

189 – Technical Success is the Sole Predictor of Successful Endoscopic Closure of Post-Surgical Gastrointestinal Leaks: A Multicenter North American Cohort

189 – Technical Success is the Sole Predictor of Successful Endoscopic Closure of Post-Surgical Gastrointestinal Leaks: A Multicenter North American Cohort

Purse-string sutures using novel endoloops and repositionable clips for the closure of large iatrogenic duodenal perforations with single-channel endoscope: a multicenter study.

Serious complications due to perforation restrict the development of duodenal endoscopic treatment. The key stage for remediation is the successful endoscopic closure to prevent peritonitis and the need for surgical intervention. This report aimed to present a new simple method for the closure of large iatrogenic duodenal perforations with purse-string sutures using the novel endoloops and repositionable clips through a single-channel endoscope. A total of 23 patients with iatrogenic duodenal perforations ≥ 1cm were retrospectively studied who were presently treated by purse-string sutures using the novel endoloops and the repositionable hemostasis clips with the single-channel endoscope at four institutes. During and after the procedure, a 20-gauge needle was used to relieve the pneumoperitoneum or subcutaneous emphysema. Finally, a gastroduodenal decompression tube was placed. The median maximum diameter of iatrogenic duodenal perforations was 1.65cm (range 1.0-3.0cm). Complete endoscopic closure of all 23 perforations was achieved. No patient had severe complications such as peritonitis. The wounds were healed and no obvious duodenal stricture was observed in all cases after 3months. Purse-string sutures using the novel endoloops and repositionable endoclips through single-channel endoscope were feasible, effective and easy methods for the closure of large duodenal iatrogenic perforations.

Endoscopic management of perforations, leaks and fistulas.

The endoscopic management armamentarium of gastrointestinal disruptions including perforations, leaks, and fistulas has slowly but steadily broadened in recent years. Previously limited to surgical or conservative medical management, innovations in advanced endoscopic techniques like natural orifice transluminal endoscopic surgery (NOTES) have paved the path towards development of endoscopic closure techniques. Early recognition of a gastrointestinal defect is the most important independent variable in determining successful endoscopic closure and patient outcome. Some devices including through the scope clips and stents have been well studied for other indications and have produced encouraging results in closure of gastrointestinal perforations, leaks and fistulas. Over the scope clips, endoscopic sutures, vacuum therapy, glue, and cardiac device occluders are other alternative techniques that can be employed for successful endoscopic closure.

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

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