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©The Author(s) 2015.
World J Gastroenterol. Oct 7, 2015; 21(37): 10542-10552
Published online Oct 7, 2015. doi: 10.3748/wjg.v21.i37.10542
Published online Oct 7, 2015. doi: 10.3748/wjg.v21.i37.10542
Location of perforation | Clinical presentation | Preferred endoscopic closure techniques | Comments |
Esophagus | Subcutaneous emphysema, neck pain, chest pain, emesis | Small perforations (< 2 cm) can be closed with clips (TTSC or OTSC) | The use of endoscopic techniques may be challenging in the proximal esophagus, due to space constraints and patient intolerance - consider conservative treatment in stable patients |
Tachycardia with chills and fever suggest mediastinitis and sepsis development | Perforations < 2 cm size with everted edges may be treated with OTSC clips | Stent fixation with clip application or suturing techniques may be useful to prevent migration of the stent | |
Large perforations (> 2 cm) or defects associated with esophageal stenosis may be managed with fully covered and partially covered SEMS or endoscopic suturing techniques | Fibrin glue application and EVAC use has been reported for closure of esophageal perforations but experiences are limited | ||
Stomach | Abdominal pain, abdominal fullness | Endoscopic clipping techniques (TTSC, OTSC) are the mainstay of gastric perforation closure | Most perforations of the stomach are small defects that occur during EMR, ESD procedures and can be successfully closed with TTSC. |
Breathing deterioration and shock symptoms suggest development of tension pneumoperitoneum | Omental patch closure technique, clipping plus endoloop or OTSC may be an option in closing large defects (> 1 cm) | Closing perforations in proximal stomach may be challenging | |
Peritonitis and abscess formation result from leakage of gastric contents | Endoscopic suturing is an optional method especially in closing post-ESD defects | Endoscopic band ligation for gastric perforation closure has been reported but experiences are limited | |
Pneumomediastinum and pneumothorax are relatively rare complications of perforations in cardiac region | Endoscopic stents may be useful to treat perforations following pyloric or gastroenteric anastomosis dilation | ||
Duodenum and biliary tract | Retroperitoneal nature of the injuries may mask the severity | Peri-ampullary or biliary tract perforations may be treated with biliary stent placement or TTSC | The use of transparent cap may be helpful in difficult locations |
The severity of perforations varies from asymptomatic retroperitoneal air alone (which is not true perforation), to life-threatening perforations with persistent pancreatic and biliary leaks into retroperitoneal or intraperitoneal space | Large perforations most often require immediate surgery. However, when the defect size < 15 mm consider perforation closure with TTSC, OTSC | Closure of medial duodenal wall defects with clips may be challenging due to risk of clipping the ampulla and anatomic location | |
Fully covered duodenal SEMS are also the therapeutic option in nonperiampullary perforations | Nasoduodenal drain to divert pancreatic and biliary secretions may be beneficial | ||
Peritonitis is a late finding associated with poor outcome | Asymptomatic patients with retroperitoneal air alone need no additional treatment | ||
Colon, Rectum | Abdominal pain, abdominal fullness, subcutaneous emphysema | Small perforations (< 2 cm) can be closed with clips (TTSC or OTSC) | The success rate of endoscopic closure is higher when the perforation is recognized and closed during the same procedure, the quality of bowel preparation is good, and there is no leakage of intraluminal contents |
Breathing deterioration and shock symptoms suggest development of tension pneumoperitoneum | Clipping plus endoloop is an option to close large colonic defects | Large vertical perforations should be closed from top to bottom, and horizontal perforations should be clipped from left to right | |
Peritonitis and abscess formation are the consequence of intraluminal fecal leakage | Endoscopic band ligation can also be useful to treat colonic perforations |
- Citation: Rogalski P, Daniluk J, Baniukiewicz A, Wroblewski E, Dabrowski A. Endoscopic management of gastrointestinal perforations, leaks and fistulas. World J Gastroenterol 2015; 21(37): 10542-10552
- URL: https://www.wjgnet.com/1007-9327/full/v21/i37/10542.htm
- DOI: https://dx.doi.org/10.3748/wjg.v21.i37.10542