Endoscopic Management of Perforations Gregory G. Ginsberg, MD Professor of Medicine University of Pennsylvania Perelman School of Medicine Gastroenterology Division Executive Director of Endoscopic Services University of Pennsylvania Health Systems Abramson Cancer Center NOLA 2018 Disclosures Olympus Inc. Consultant Boston Scientific Consultant Interscope Clinical Research Fractyl Consultant Off-Label Use Discussed: Self-expanding esophageal stents for benign indications 1
Patch, Plug or Clip: Endoscopic Management of Perforations, Fistulas and Leaks Learning objectives: Know the options for endoscopic management of acute colonic perforation and of acute and chronic UGI perforations, leaks and fistulae Acute Colonic Perforation Polypectomy vs. scope-mediated Size matters Location matters Asses the patient s condition CO2 insufflation gas minimizes symptomatology Consider the quality of the preparation Be prepared with a plan 2
CAUSES of COLON PERFORATION Frequency Fecal Diversion 27% 18% 55% 62.5 50 37.5 25 12.5 0 2.0 cm 0.9 cm 1.4 cm Iqbal J Gastrointest Surg 2005 Courtesy of Raju PREVENTION OF PERFORATION HOCKEY STICK INJURY RETROFLEXION INJURY BAROTRAUMA INJURY ANGULATED SIGMOID Thin instrument REDUNDANT SIGMOID Balloon assisted endoscopy Overtubes Water immersion Left lateral 2 prone position SMALL RECTUM Avoid retroflexion Cap fitted colonoscope helps in examining the lower rectum Courtesy of Raju DIFFICULT INSERTION CLOSED LOOPS Use CO2 Periodic decompression Water Immersion 3
Sydney Classification of Deep Mural Injury (DMI) following EMR Burgess NG, et al. Gut 2016;0:1 11. 0 1 2 3 4 Consequences of Delay in Recognition of Perforation 4
Delay in Recognition 3/4 post procedure 70 52.5 Ostomy n=180 1/4 1980-2006 % 35 17.5 Mana et al. GIE 2001;53:258-9 Iqbal J Gastrointest Surg 2005 1/4 in > 24 hours 0 <24 hrs >24 hrs Acute perforation noted endoscopically 5
UGI Perforations, Leaks and Fistulae Etiologies Iatrogenic Operative Anastomotic, Bariatric, Heller myotomy Endoscopic EMR, ESD, dilation, PEG Malignant T-E fistula Environmental Boerhaave syndrome Endoscopic therapies Stents FCSEMS, PCSEMS, FCSEPS Closure TTS clips OTS clips Suturing Sealants Fibrin glue Tissue plugs Tools for Perforation, Leaks and Fistulas 6
Managing UGI Perforations, Leaks and Fistulae Timing Acute vs Delayed vs Chronic Location Mediastinal vs Peritoneal vs Retroperitoneal Etiology Endoscopic vs Operative vs Environmental Colonization Likely infected vs sterile Esophageal perforations Small (<5-10mm) (<15% of circumference) Intermediate (>5-10 and <30mm) (>15% and <50% of circumference) Large (>30 mm) (>50% of circumference) ENDOCLIP STENT Endo- SPONGE SEALANT OTSC SUTURING SURGERY Infectious complications (-) Infectious complications (+) <3 hr <24 hr <1/>1 week PapanikolaouIS, Siersema PD. Chapter 21: Esophageal perforation In: ThamT, Collins J, SoetiknoR, eds. Gastrointestinal Emergencies Oxford: Blackwell Publishing Ltd 2008 Courtesy: Siersema 7
Acute, Iatrogenic, Endoscopic Perforation Endoscopic closure Through-the- Scope (TTS) clips 115 (98.3%) of 117 patients with gastric perforations were successfully treated conservatively using endoscopic clips for closure of their perforations. Single closure Edge to center Omental patch Gastrointest Endosc. 2006; 63: 596 601. W J Gastroenterol 2013;19(4): 528-535 TTS Clip Closure 8
Management of Acute Non-Iatrogenic Esophageal Perforations High morbidity and mortality (10-40%) Individualized therapy Should only be undertaken with multidisciplinary collaboration Thoracic Surgery, Diagnostic Imaging Supporting evidence is level C-D Retrospective series Expert opinion Predictors of Successful Non- Operative Management 9
Stent Therapy Ben-David, et al J Am Coll Surg 2014;218:768 76 consecutive acute EP Median age 64 90% distal esophagus 67% iatrogenic NPO, IV antibiotics < 24 hrs covered stent placement Serial Gastrografin swallow to confirm leak sealed Mean ICU stay 3 days Chest drainage of visible collections 1/3 prolonged intubation Nutrition support Stenting for Benign Indications Goal: Durable tissue remodeling SEPS Fully covered Approved for benign indications SEMS Fully covered Not approved for benign indications Partially covered Not approved for benign indications Epithelial hyperplasia Blessing and a curse 10
Fully Covered SEPS Expandable Polyester Siliconecovered Retrievable FDA approved for BRES Migrated SEPS 30% stent migration Durable stricture resolution 23% Repici, et al. GI Endosc 2004;60:513. 11
Retrospective analysis from 6 referral centers A total of 329 stents were removed including 265 (80.5%) SEMS fully covered N = 171 (64.5%) partially covered N = 94 (35.5%). 64 (19.5%) SEPS Indications benign strictures N = 158 (48.0%) fistulas N = 164 (49.8%). Mean stenting time was 60 days (inter-quartile range 57, range 0 659 days). At time of removal 91 (27.7%) stents had migrated 15 stents (4.6%) severely embedded by granulation tissue. Majority of stent removed with grasping forceps or snare Stent-in-stent technique for embedded SEMS 7 biodegradable stents 4 FCSEMS 1 SEPS both stents removed as one using a RTF after a mean 12 days (range 6 21) 35 (10.6%) removal-related complications 7 (2.1%) major complications perforation 3 (0.9%), esophageal avulsion 1 (0.3%), stridor requiring intubation 1 (0.3%), embedment requiring surgical removal 1 (0.3%) and fistula 1 (0.3%). 12
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Endoscopic Management of Perforations Summary: Be familiar with the diagnosis and management of acute endoscopic and operative leaks and perforations Know the options for endoscopic management of acute perforation Be knowledgeable about opportunities and limitations for treating chronic leaks and fistulae 14