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GE-Portuguese Journal of Gastroenterology

versão impressa ISSN 2341-4545

GE Port J Gastroenterol vol.21 no.5 Lisboa out. 2014

https://doi.org/10.1016/j.jpg.2014.05.006 

POSITION PAPER

 

What to expect from the ‘‘bear claw’’? The initial Portuguese experience with the over-the-scope clip system

O que esperar da ‘‘garra de urso’’? A experiência inicial portuguesa com o sistema over-the-scope clip

 

Miguel Bispoa,b

a Serviço de Gastrenterologia, Centro Hospitalar de Lisboa Ocidental - Hospital de Egas Moniz, Portugal

b Centro de Gastrenterologia e Endoscopia Digestiva, Hospital da Luz, Portugal

E-mail address: mbispo@hospitaldaluz.pt

 

Until recently, surgery was the mainstay therapy for large gastrointestinal (GI) leaks, with inherent morbidity/ mortality and high costs.1 Endoscopic treatments for GI leaks (including postoperative dehiscences, fistulas and endoscopic perforations) have quickly evolved in the last decade. The endoscopic approach to postoperative dehiscences and fistulas has traditionally included covered self-expandable metal stents, various sealants/glues and regular clips, but these options have several limitations.2,3 Although standard endoscopic clips are familiar and readily available, their application is technically limited to small and regular wall defects and may result in a superficial mucosal suture (rather than a durable full-thickness wall closure).4,5 The main concern regarding endoscopic perforation management with standard clips is that the metallic clips might not close a larger wall defect firmly enough and once the clips drop off peritonitis can occur. A novel single loop-and-clips closure technique (KING closure), where the leak is closed with clips and an endoloop is then placed to fix and tighten all of the clips together, has shown promising results in the closure of perforations after endoscopic full-thickness resection of subepithelial tumors.6,7

The ‘bear-claw’ or over-the-scope clip (OTSC) system (Ovesco Endoscopy, Tubingen, Germany) is a new clipping device developed for closure of large GI wall defects.8 This clip is preloaded on a cap fitted onto the endoscope tip, similarly to band-ligation systems. When the clip is released from the applicator cap, it closes because of a ‘‘shape-memory’’ effect (a bear-trap like mechanism). On deployment, it is capable of capturing significantly larger amounts of tissue, with more force exerted for tissue apposition.4

A key element to technical success when using the OTSC is to accurately position the wall defect within the OTSC cap.9 An anchoring or grasping device can facilitate the approximation of tissue margins before the OTSC is released.  An emerging application for the OTSC system is major GI bleeding, particularly in large and fibrotic bleeding ulcers refractory to conventional endoscopic treatments.10,11

In this issue of GE - Portuguese Journal of Gastroenterology, Correia et al. report the first Portuguese case series of patients undergoing OTSC placement for gastrointestinal leaks. In this retrospective series from a tertiary referral centre, six consecutive patients underwent OTSC placement by two endoscopists (with previous experience on OTSC placement in animal models), mainly for post-surgical or chronic fistulas of the gastrointestinal tract (only one patient underwent OTSC placement for an acute post-polipectomy perforation). The visceral leaks had defect diameters of 7-12mm, were mostly located in the upper digestive track (only two in the colon) and had fibrotic edges in most cases (three post-surgical dehiscences and two benign esophagealrespiratory fistulas). In these chronic leaks, there was a large time interval between the diagnosis and the OTSC placement (33-153 days) and previous attempts of endoscopic treatment using self-expandable stents had failed in two cases. Successful OTSC application and immediate closure of the leak were achieved in all cases, with no complications. Long-term healing of the leaks was assessed by endoscopic or radiological means and failed only in one patient.

This first Portuguese single-centre study has confirmed the favourable results of the OTSC system for treatment of gastrointestinal leaks reported in other series and in a recent systematic review.9,12,13 Moreover, the patients included in this study were very complex, mostly resistant to previous attempts of endoscopic or surgical treatments, with a large time interval between the leak diagnosis and the OTSC placement. As previously reported in the literature, a major drawback preventing successful OTSC application is the presence of fibrotic or inflamed leak edges.13 As pointed out by the authors, the only case of clinical failure (with fistula recurrence) was referred to endoscopic treatment very late (153 days after diagnosis).

The results presented by Correia et al. seem promising and support the efficacy and safety of the OTSC in the management of GI leaks, even in complex cases, although this is a small case series. It has been previously shown that the OTSC allows the closure of leaks as large as 27mm14; however, it is only approved by the FDA to close defects smaller than 20mm in size, and complex geometries could yield less-consistent results.9 Randomized clinical trials regarding OTSC treatment of GI leaks are missing and the evaluation of the OTSC efficacy is essentially based on small case series.13 A benefit in the management of large GI perforations, in terms of technical feasibility and effectiveness, has not been shown in a recent randomized experimental study comparing the OTSC system and the KING closure technique.15

Novel endoscopic approaches and technologies to manage larger perforations, defects with complex geometry, and even those complicated by leak of luminal contents, continue to evolve. The OverStitch (Apollo Endosurgery, Austin, Tex) is an endoscopic suturing device that allows full-thickness tissue apposition, with a variety of suture patterns, via an endoscopic platform.16 A novel method of endoscopic abdominal exploration through the perforation site and full-thickness closure using the OverStitch was recently described by Kumar and Thompson.17 In this recent report, the authors have demonstrated successful management of two large complex perforations, complicated of peritoneal contamination, with the use of endoscopic abdominal exploration and OverStitch closure, in a single session in the endoscopy suite.17

Although these innovative endoscopic approaches, as the promising experience with the OTSC reported by Correia et al., may initially be confined to centres with the necessary equipment and expertise, they are encouraging and represent the full potential of endoscopy in the optimization of patient care.

 

References

1. Schecter WP, Hirshberg A, Chang DS, Harris HW, Napolitano LM, Wexner SD, et al. Enteric fistulas: principles of management. J Am Coll Surg. 2009;209(4):484-91.         [ Links ]

2. Bege T, Emungania O, Vitton V, Ah-Soune P, Nocca D, Noel P, et al. An endoscopic strategy for management of anastomotic complications from bariatric surgery: a prospective study. Gastrointest Endosc. 2011;73(2):238-44.         [ Links ]

3. Eisendrath P, Cremer M, Himpens J, Cadiere GB, Le Moine O, Deviere J. Endotherapy including temporary stenting of fistulas of the upper gastrointestinal tract after laparoscopic bariatric surgery. Endoscopy. 2007;39(7):625-30.         [ Links ]

4. von Renteln D, Vassiliou MC, Rothstein RI. Randomized controlled trial comparing endoscopic clips and over-the-scope clips for closure of natural orifice transluminal endoscopic surgery gastrotomies. Endoscopy. 2009;41(12):1056-61.         [ Links ]

5. Zhang Y, Fan Z. Is closure of only the mucosal layer really sufficient? Endoscopy. 2014;46(01):82.         [ Links ]

6. Shi Q, Chen T, Zhong YS, Zhou PH, Ren Z, Xu MD, et al. Complete closure of large gastric defects after endoscopic full-thickness resection, using endoloop and metallic clip interrupted suture. Endoscopy. 2013;45(5):329-34.         [ Links ]

7. Ye LP, Yu Z, Mao XL, Zhu LH, Zhou XB. Endoscopic full-thickness resection with defect closure using clips and an endoloop for gastric subepithelial tumors arising from the muscularis propria. Surg Endosc. 2014;28(6):1978-83.         [ Links ]

8. Kirschniak A, Kratt T, Stuker T, Braun A, Schurr MO, Konigsrainer A. A new endoscopic over-the-scope clip system for treatment of lesions and bleeding in GI tract: first clinical experiences. Gastrointest Endosc. 2007;66:162-7.         [ Links ]

9. Baron TH, Wong Kee Song LM, Zielinski MD, Emura F, Fotoohi M, Kozarek RA. A comprehensive approach to the management of acute endoscopic perforations (with videos). Gastrointest Endosc. 2012;76:838-59.         [ Links ]

10. Chan SM, Chiu PW, Teoh AY, Lau JY. Use of the over-the-scope clip for treatment of refractory upper gastrointestinal bleeding: a case series. Endoscopy. 2014;46(5):428-31.         [ Links ]

11. Manta R, Galloro G, Mangiavillano B, Conigliaro R, Pasquale L, Arezzo A, et al. Over-the-scope clip (OTSC) represents an effective endoscopic treatment for acute GI bleeding after failure of conventional techniques. Surg Endosc. 2013;27(9):3162-4.         [ Links ]

12. Voermans RP, Le Moine O, von Renteln D, Ponchon T, Giovannini M, Bruno M, et al. Efficacy of endoscopic closure of acute perforations of the gastrointestinal tract. Clin Gastroenterol Hepatol. 2012;10(6):603-8.         [ Links ]

13. Weiland T, Fehlker M, Gottwald T, Schurr MO. Performance of the OTSC system in the endoscopic closure of iatrogenic gastrointestinal perforations: a systematic review. Surg Endosc. 2013;27(7):2258-74.         [ Links ]

14. von Renteln D, Schmidt A, Vassiliou MC, Rudolph HU, Caca K. Endoscopic full-thickness resection and defect closure in the colon. Gastrointest Endosc. 2010;71(7):1267-73.         [ Links ]

15. Martinek J, Ryska O, Tuckova I, Filipkova T, Doleˇzel R, Juhas S, et al. Comparing over-the-scope clip versus endoloop and clips (KING closure) for access site closure: a randomized experimental study. Surg Endosc. 2013;27(4):1203-10.         [ Links ]

16. Jirapinyo P, Slattery J, Ryan MB, et al. Evaluation of na endoscopic suturing device for transoral outlet reduction in patients with weight regain following Roux-en-Y gastric bypass. Endoscopy. 2013;45:532-6.         [ Links ]

17. Kumar N, Thompson CC. A novel method for endoscopic perforation management by using abdominal exploration and full-thickness sutured closure. Gastrointest Endosc. 2014;80(1):156-61.         [ Links ]

 

Received 13 May 2014; accepted 20 May 2014

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