Endoscopic management for gastrointestinal leaks, perforations, and fistulae: Technical tips and outcomes

Figure 1 Closure of gastric endoscopic submucosal dissection defect using mantis clips. A: Image of mantis clip showing anchor prongs; B: Mantis clip anchored to one edge of the distal part of a large post-endoscopic submucosal dissection gastric defect; C: The margin is pulled by clip for apposition and applied to the opposite margin; D: Second clip being anchored to defect margin; E: Margin mobilized and clip being applied to oppose the two margins; F: Multiple clips applied to completely close the defect.

Figure 2 Closure of post-endoscopic submucosal dissection perforation of a duodenal neuroendocrine tumor using endoscopic clip-and-loop technique (King’s closure). A: Clip applied to fix the loop along the defect margin; B: Multiple clips being applied; C: Clips along the defect margin holding the loop; D: Final clip applied at the proximal defect margin; E: Loop applicator being applied to the loop end for closure; F: Loop applied with defect closure.

Figure 3 Closure of post-endoscopic retrograde cholangiopancreatography duodenal perforation using over-the-scope-clip. A: A large duodenal perforation on the lateral wall at D1-D2 junction with surrounding friable mucosa with bleeding is visualized using a double channel therapeutic scope with an over-the-scope-clip (OTSC) mounted clip; B: One edge of the perforation grasped using the OTSC twin grasper; C: The grasped edge was taken to the opposite end and other edge grasped using the OTSC twin grasper; D: After grasping and approximating both perforation edges, the whole complex was pulled inside the cap; E: After ensuring adequate clip position to ensure optimum margins closure, suction was applied and the OVESCO clip (size 12/6t, OVESCO Endoscopy AG, Tuebingen, Germany) was deployed; F: Post-procedure abdominal X-ray shows the deployed OTSC clip (yellow solid arrow), a naso-jejunal tube (solid orange arrow), subcutaneous emphysema (white asterisk) and air outlining the right peri-nephric area and under surface of liver (dotted white arrow), signifying retroperitoneal duodenal perforation.

Figure 4 Closure of rectovaginal fistula using over-the-scope-clip. A: Double channel therapeutic scope with over-the-scope-clip (OTSC) mounted clip shows rectovaginal fistula; B: OTSC anchor opened inside the fistulous opening; C: Tissue pulled inside the cap with Anchor along with application of suction; D: Final deployed OVESCO clip (14/6t) leading to closure of rectovaginal fistula.

Figure 5 Management of mega stent migration placed for an anastomotic dehiscence (leak) using a Stentfix over-the-scope-clip system. A and B: Under endoscopic and fluoroscopic guidance using a standard gastroscope with a mounted over-the-scope-clip (OTSC) cap and OTSC system, the edge of the previously placed mega stent was approached, which was targeted to be fixed; C and D: Suction was applied and clip was deployed, which anchored the stent and prevented further stent migration.

Figure 6 Management of esophageal-jejunal anastomotic leak using a mega stent in a case of post-operative Whipple procedure with total gastrectomy for periampullary carcinoma with contiguous stomach involvement. A: Endoscopic appearance of the anastomotic site, which shows the site of leak (white dotted arrow), efferent jejunal loop opening (yellow solid arrow), afferent jejunal loop opening (black solid arrow) and esophageal-jejunal anastomosis (white solid asterisk); B: Oral contrast study shows visible active leak at the site of anastomosis; C: Under fluoroscopic and endoscopic guidance, a steel guidewire was placed in the efferent limb of the jejunum and stent was loaded on the guidewire; D: A 24 mm × 23 cm mega stent (Niti-S fully covered self-expanding metal stent, Taewoong Medical, South Korea) was deployed in the efferent limb covering the anastomosis site and leak; E: Contrast study showing no leak and contrast flowing into the distal jejunum; F: Repeat endoscopy after 1 week, showing optimally placed stent into the distal jejunum, covering the leak site.

Figure 7 Endoscopic vacuum therapy for post-esophagectomy with gastric pull-up surgery anastomotic leak with cavity. A: The cavity after cleaning debris and slough removal (green asterisk-esophageal lumen); B: Endosponge fashioned as per the shape and size of the cavity and sewed over a 12 Fr Ryle's tube; C: Placement of the endosponge inside the cavity using foreign body forceps; D: Endosponge placed inside the cavity completely covering the cavity; E: Follow-up image showing endosponge in place with adherent pus and debris; F: Cavity collapsed after six sessions of endoscopic vacuum therapy.

Figure 8 Closure of post-endoscopic submucosal dissection defect of gastric subepithelial lesion using X-Tack™ endoscopic HeliX tacking system. A: Application of the first tack at the apex of the defect; B: Second tack applied along the left margin of the defect; C: Two tacks placed with continuous suture line visible; D: Third tack applied along the right margin of the defect and traction on the suture line to oppose the margin; E: Fourth tack applied at the proximal margin of the defect; F: Suture cinch being applied to close the defect.

Figure 9 Algorithm for the management of gastrointestinal leaks or perforations. NPO: Nil per oral; IV: Intravenous; CT: Computed tomography; TTSC: Through the scope clip; OTSC: Over the scope clip; UGI: Upper gastrointestinal; LGI: Lower gastrointestinal.

Figure 10  Algorithm for the management of gastrointestinal fistulae. TTSC: Through the scope clip; OTSC: Over the scope clip.