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www.elsevier.pt/ge

RIGINAL ARTICLE

ndoscopic management of digestive leaks with thever-The-Scope Clip: A retrospective study

ito Correiaa,∗, Pedro Amaroa, Ana Oliveiraa, Alexandra Fernandesa,iogo Branquinhoa, Ana Nunesb, Francisco Portelaa, Carlos Sofiaa

Gastroenterology Department --- Centro Hospitalar e Universitário de Coimbra, Coimbra, PortugalGastroenterology Department --- Hospital Garcia de Horta, Almada, Portugal

eceived 14 January 2014; accepted 27 March 2014vailable online 24 May 2014

KEYWORDSOver-The-Scope clip;Gastrointestinalleaks;Fistula;Perforation

AbstractIntroduction: The Over-The-Scope Clip (OTSC®) is a device with promising applications in endo-scopic closure of perforations/dehiscence/fistulas, endoscopic hemostasis and NOTES.Aims: To evaluate the clinical effectiveness and safety of OTSC.Methods: Between September 2011 and September 2013, 6 consecutive patients underwentOTSC placement by two experienced endoscopists. In three patients OTSC was used in theclosure of surgical dehiscences, both in upper digestive tract (after esofagojejunostomy andgastric sleeve) and in lower digestive tract (blind loop dehiscence after colorectal anastomosis).Two patients had esophageal fistulas with several weeks’ duration (one to the bronchial tree andother to the pleura). Furthermore, OTSC was used to close an iatrogenic perforation followingcolonic polipectomy.Results: All procedures experienced technically immediate success and there were nocomplications related to the placement of the OTSC (1 clip). It was well tolerated and patientswere hospitalized on average 15 days (5---53 days). However, during follow-up (mean = 12.4;5---22 months) permanent closure of chronic esophageal-bronchial fistula could not be achievedin one patient.Conclusion: In our experience, OTSC shows efficacy in solving gastrointestinal leaks.

© 2014 Sociedade Portuguesa de Gastrenterologia. Published by Elsevier España, S.L.U. All rightsreserved.

∗ Corresponding author.E-mail address: Titocorreia@gmail.com (T. Correia).

ttp://dx.doi.org/10.1016/j.jpg.2014.03.003341-4545/© 2014 Sociedade Portuguesa de Gastrenterologia. Published by Elsevier España, S.L.U. All rights reserved.

Endoscopic management of digestive leaks 185

PALAVRAS-CHAVEOver-The-Scope clip;Deiscênciagastrointestinal;Fístula;Perforacão

Resolucão de fugas digestivas com Over-The-Scope Clip: análise retrospectiva

ResumoIntroducão: O endoclip Over-The-Scope (OTSC) é um acessório com possíveis aplicacões noencerramento de perfuracões/deiscências/fístulas, hemostase endoscópica e em NOTES.Objectivo: Avaliar a eficácia clínica e seguranca do OTSC.Métodos: Entre Setembro de 2011 e Setembro de 2013, seis pacientes consecutivos foram sub-metidos à colocacão OTSC por dois endoscopistas com experiência em modelos animais. Emtrês pacientes o OTSC foi utilizado no encerramento de deiscências cirúrgicas, tanto no tractodigestivo superior (após esofagojejunostomia e sleeve gástrico) como no tracto digestivo infe-rior (deiscência de ansa cega após anastomose colorretal). Dois pacientes apresentaram fístulasesofágicas com duracão de várias semanas (um para a árvore brônquica e outro para a pleura)que dificultou a colocacão do OTSC. O OTSC foi usado, igualmente, para fechar uma perfuracãoiatrogénica após polipectomia do cólon.Resultados: Todos os procedimentos obtiveram sucesso técnico imediato e não se observaramcomplicacões relacionadas com a colocacão do OTSC (1 clip). O procedimento foi bem toleradoe os pacientes permaneceram internados, em média, 15 dias (5---53 dias). No entanto, duranteo acompanhamento (média=12,4; 5---22 meses) o encerramento definitivo de fístula esôfago-brônquica crônica não foi possível em um dos pacientes.Conclusão: O OTSC provou a sua aplicabilidade na resolucão de solucões de continuidade gas-trointestinais.

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Introduction

Post-surgical complications such as fistula and anasto-motic leaks are conventionally submitted to surgical repair(open, laparoscopic or external drainage). However, surgi-cal reintervention has a significant morbidity and mortality,prolongs hospital stay and increases the costs.1 Severalendoscopic techniques have been described for closure ofgastrointestinal leaks (perforations, leaks, and fistulas) byusing various devices and methods such as clipping withmultiple metallic endoclips,2---4 ligating with endoloops andrubber bands,5 fibrin glue sealing,6 prolene mesh plug-ging and application of cyanoacrylate,7 clips and endolooptogether by using a double channel endoscope.8 In 2007,Kirschniak et al. described the first cases of small mural leaksclosure with a new endoclip system, the over-the-scope clip--- OTSC® (Ovesco Endoscopy, Tuebingen, Germany).9 Thisendoclip is made of super-elastic shape memory nitinol alloy(MRI-safe material), which resumes its former unbent shapeafter the clip is released and exerts a more sturdy closurecompared to conventional endoclips due to its capacity tograsp more visceral tissue and apply a greater compres-sive force. The system consists of a clip that is preloadedon a transparent applicator cap mounted on the endo-scope tip, which can be released by pulling a taut wirethreaded through the working channel to the hand-wheel ofthe scope, similar to band-ligation systems. Recently, caseseries and reviews have been published describing its suc-cess in treatment of gastrointestinal bleeding, fistula, andperforations.10---18

The present retrospective study, performed within the

endoscopy unit of a tertiary referral center, evaluatedthe clinical effectiveness and safety of the OTSC systemin the management of non-malignant gastrointestinal tractwall leaks.

apud

Gastrenterologia. Publicado por Elsevier España, S.L.U. Todos

atients and procedures

linical cases of six consecutive patients that underwentTSC placement between September 2011 and September013 were reviewed. Patient characteristics are summa-ized in Table 1. The OTSC system was mounted onto theip of a gastroscope (Olympus GIF-1T Q160; diameter of.8 mm; working channel of 2.8 mm; Olympus, Tokyo, Japan)n the same manner as a band ligation device. ‘‘Traumatic’’ersion (t type) of OTSC, medium sized caps twin typeraspers (OTSC Twin Grasper® Ovesco Endoscopy, Tuebingen,ermany) and anchor (OTSC Anchor®, Ovesco EndoscopymbH, Tuebingen, Germany) were used. Two endoscopistsith previous experience in animal models performed thepplication of the device. All procedures took place underonscious sedation with intravenous midazolam or deepedation with intravenous propofol.

All procedures were performed by two advanced endo-copists with experience of OTSC placement in animalodels.To all patients had been previously explained the ther-

peutic procedure and all signed the respective informedonsent.

esults

systematic approach of the data, including patient proce-ure details, technical and clinical outcomes, is representedn Table 1.

Patient 1: A 71-year-old man underwent total gas-rectomy and Roux-en-Y esofagojejunostomy for gastric

denocarcinoma. A blind loop jejunal dehiscence and com-lex fistula occurred 10 days later. After a couple of weeksnder antibiotherapy and external drainage, he suddenlyeveloped dyspnea and hemoptysis. New CT and barium

186T.

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Table 1 Patient characteristics, procedure details and long-term clinical outcome. AB --- antibiotherapy; ED --- External drainage; M---W --- Mallory---Weiss; M --- male; F --- female;S --- successful; d --- days; m --- months.

Characteristics Patient number

1 2 3 4 5 6

Age/Gender 71/M 84/M 36/F 66/F 71/F 63/MLocation of the leak Blind loop

jejunaldehiscence

Blind loopcolorectalanastomosis

Longitudinalgastric suture ---sleevegastrectomy

Esophago-bronchialfistula

Esophago-pleuralfistula

Sigmoid colon

Indication Post surgicalfistula

Post surgicalfistula

Post surgicalfistula

Spontaneousesophageal rupture

Post M---Wperforation

Postpolipectomyperforation

Time from diagnosis toOTSC placement (d)

54 78 40 153 33 0

Maximum lesion size(mm)

12 9 11 7 9 10

Additional treatment ED + AB ED + AB Relaparoscopy + ED + AB Surgery + AB + Esophagealstent

ED + AB AB

Hospital stay after OTSCplacement (d)

7 7 5 53 14 6

Technical immediateoutcome

S S S S S S

Duration of follow-up(m)

22 15 13 Lost at follow-up 7 5

Clinical outcome Asymptomatic Asymptomatic Asymptomatic Persistence offistulous track

Asymptomatic Asymptomatic

Endoscopic management of digestive leaks 187

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Figure 1 Patient 2 --- Colon blind loop dehiscence in a color

transit described a transdiaphragmatic tract linking theabdominal collections to a lung abscess with fistula tothe bronchial tree. Despite broad-spectrum antibiotics andexternal drainage, there was progressive clinical deterio-ration due to severe septic shock, not allowing surgicalapproach. Endoscopy was then performed which revealeda 12 mm dehiscence of the Roux-en-Y blind loop closure. Asit has not been possible to aspirate the fistula hole into thedevice it was decided to suck the entire circumference ofnormal mucosa upstream the orifice, creating a new closureof the loop by the placement of the OTSC. The immedi-ate clinical response was extremely favorable, as evidencedby the swift recovery from the septic state and resolutionof the suppurated abdominal fistula to the bronchial tree.The patient remains asymptomatic after 17 months of followup.19

Patient 2: An 84-year-old man underwent anterior rec-tal resection for rectal cancer, with protective ileostomyand colorectal anastomosis. Two weeks after the surgery,an anastomotic dehiscence was diagnosed by CT, whichidentified a pre-sacral abscess (12 cm × 6 cm), close to sur-gical anastomosis, as well as air in the retroperitoneum.After pelvic drainage and antibiotitherapy there was clin-ical improvement. However, soon after, he developed pelvicpain and fever, and CT and barium transit confirmed per-sistence of colorectal anastomosis dehiscence and pelvicabscess. Endoscopy, revealed a fistulous orifice in the colonblind loop (Fig. 1a). Leak margins were easily grasped withthe OTSC anchor and invaginated into the applicator cap andthe wall was closured by a OTSC with occlusion of the fis-tula lumen (Fig. 1b). The patient fully recovered and wasdischarged after seven days.

Patient 3: A 36-year-old woman underwent laparoscopicsleeve gastrectomy for obesity. She presented on the fif-teenth postoperative day with abdominal pain, fever andvomiting. CT revealed a postoperative leak in the proxi-mal third of the gastric sleeve. Initially, a new laparoscopicapproach was performed, with abdominal abscess drainage,fistula rafia and abdominal drains were placed. Symptomspersisted and an esophagogastroduodenoscopy confirmedthe maintenance of the gastric fistula. Subsequent place-ment of fully covered esophageal stent (Poliflex®, 12 cm

long, 20 mm diameter) was possible and assisted to clini-cal improvement. However, shortly thereafter, the patientdeveloped obstructive symptoms and maintained purulentmaterial by surgical drains. Endoscopically, prior esophageal

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l anastomosis before (a) and after (b) treatment with OTSC.

tent was removed (medium part was damaged) upkeepinghe gastric fistula and a OTSC was deployed. The patientresented clinical (purulent drainage stopped) and imagio-ogical improvement (no contrast leak). At follow-up, theatient continued to tolerate oral intake, maintaining a sta-le weight, without abdominal pain or fever.

Patient 4: A 66-year-old woman underwent surgicalsophogorraphy after spontaneous rupture of the esoph-gus. Three months later she developed symptoms ofsophago-bronchial fistula, confirmed by endoscopy andarium transit. Medical and endoscopic treatments wereerformed with placement of three partially covered self-xpandable stents, which presented distal migration. Theatient showed clinical improvement with resolution ofstula in the barium transit. Six months after she pre-ented with fever and a respiratory infection was diagnosed.sophagogastroscopy was performed and two small holesompatible with esophageal-bronchial fistula were iden-ified in the mid esophagus. She was referred to ourepartment and an OTSC was deployed after traction withn anchor with apparent closure of the fistulous orifice, con-rmed by contrast study (Fig. 2 a---c). A few days after, theatient developed a respiratory exacerbation and it was ver-fied the absence of the esophageal OTSC. The persistence ofhe fistulous track (Fig. 2d) led to a new surgical approach,lso without success.

Patient 5: A 71-year-old women presented withematemesis due to Mallory---Weiss tear. A few days laterhe developed sepsis consequent to respiratory infection,ith right pleural effusion. Placement of chest drain iden-

ified purulent liquid. After resumption of oral feeding, itas observed food content in pleural drainage, confirmedy contrast examination with identification of fistulous trackith about 5 cm from the distal esophagus to the right pleu-

al space (Fig. 3a and b). Persistence of pleural effusion ledo endoscopic attempt to closure the fistulous orifice usingndoclip OTS with anchor (Fig. 3c). During the procedureethylene blue was instilled in the lumen, and no drainagey the chest tube was identified. New contrasted study tooklace 15 days after OTSC placement, which showed no leak-ge of the contrast product (Fig. 3d). Clinically, the patientesumed oral feeding, without evidence of recurrence of the

stula or other complications.

Patient 6: A 63-year-old man previously healthy under-ent elective colonoscopy in our department to performolypectomy. At 45 cm from the anal margin, there was a

188 T. Correia et al.

Figure 2 Patient 4 --- Esophageal-bronchial fistula: endoscopic view before (a) and after (b) OTSC placement; (c) contrasted studyone day after OTSC (red arrow) placement; (d) persistence of the fistulous track (blue arrow) in CT.

Figure 3 Patient 5 --- Esophageal-pleural fistula after perforation of a Mallory---Weiss tear: (a) fistulous orifice with pus (blue arrow);(O

b) esophageal-pleural fistula in contrast study; (c) endoscopic viewTSC.

after OTSC placement; (d) contrast image after treatment with

Endoscopic management of digestive leaks 189

Figure 4 Patient 6 --- (a) Endoscopic view before OTSC placement; (b) pneumoperitoneum immediately after perforation closure;

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(c) pneumoperitoneum 3 days after OTSC placement.

large and bulky sessile polyp, with a multilobulated surface,measuring about 5 cm in diameter. After mucosal elevationwith diluted epinephrine and methylene blue, the polyp wasremoved with a snare. Upon verification of the scar, therewas a perforation of 10 mm (Fig. 4b). Using a therapeu-tic gastroscope, the colic perforation was closed using anOTSC, with apparent success. The residual polypoid tissuewas also removed with a snare. The patient was admittedunder broad-spectrum antibiotics and no oral intake. Heshowed positive clinical, analytical and radiological evolu-tion (Fig. 4c), and three days after the event liquid diet wasintroduced. He was discharged asymptomatic, seven daysafter admission.

Discussion

Spontaneous or iatrogenic perforation of the gastroin-testinal tract wall may cause a variety of clinical settings,ranging from an asymptomatic course up to severe (and evenlethal) complications, requiring prompt closure and controlof extraluminal fluid collections and sepsis. Anastomoticleaks are probably the most dreaded complications ofintestinal surgery, with mortality rate often reported to beup to 10---15%.20 The incidence of intestinal anastomoticleaks ranges from 1 to 19% depending on the location of theanastomosis. However, small bowel anastomosis tends tobe associated with a lower risk of anastomotic disruptionthan large bowel anastomosis, particularly when comparedto the distal rectum or anal canal.20 Anastomotic leakagesfollowing esophagectomy occur in about 10% of cases.Anterior rectal resections lead to anastomotic leakages in9.6% if a diverting ileostomy is used, with even higher ratesif an ileostomy is omitted.20

In endoscopic procedures, the risk of perforation dependsessentially on the purpose of the exam. Perforation occurby accident in 0.06---0.12% of diagnostic colonoscopies.21,22

However, reported perforation rates are 0.3---0.5% afterendoscopic mucosal resection and 4---10% in endoscopic sub-mucosal dissection, and hence substantially higher thanconventional endoscopic procedures.23

Until recently, iatrogenic or surgical leaks were surgicallymanaged, using a diversity of procedures (proximal diver-sion, omentoplasty) combined with percutaneous drainageand intravenous antibiotics. Nonetheless, direct surgical

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epair is difficult, hazardous and often not feasible. Recentdvances in endoscopic techniques have improved thereatment of this severe event using endoclips and self-xplandable stents. The choice to treat a perforationndoscopically is made on the basis of the cause, loca-ion, duration and severity of the perforation, patient’sge and general health and, finally, on the endoscopist andurgeon’s experience. Furthermore, endoscopic treatmentllows shorter hospitalization, a negligible morbidity andortality, prompt resumption of an oral diet and reduced

osts.24

Since 1993 several series of endoscopic closure usingndoclips have been described in literature, involvinghe esophagus, stomach, duodenum-jejunum and colon-ectum.2---7 Conventional endoclips (metallic double-prongedlips introduced through the operative channel of the scope)re used for the management of bleeding and perforations.owever, they have limitations, namely restricted openingistance between the jaws and low closure force, whichamper its use in the presence of scarred and hardened tis-ue or inflammatory mucosa. It is common experience thathigh number of clips are necessary to treat gastrointesti-

al leaks. The use of self-expandable stents is effective forealing and healing chronic gastrointestinal dehiscence. Yet,emoval of partially covered stents may be difficult due tongrowth at uncovered ends with the risk of mucosal tears,hereas fully covered stents show a migration rate up to0% and often require replacement.25 Although the successate is satisfactory, healing can sometimes take months toccur, and many patients experience a slew of added mor-idities while they wait: alkaline and acid reflux, epigastricain, downright intolerance.

The choice of OTSC technique in the cases presented wasased not only on the nature of the injury but also becausef the unique characteristics of the clip itself. Indeed, thisew approach has proved to be useful in similar situations,n which alternative options were lacking.11,12,15---17,26 Properpplication of OTSC requires perfect coaptation with thenjury and aspiration of tissues into the ‘‘cap’’ so that theyan be captured on release of the clip. Alternatively, theissues can be pulled using the devices handled through

he working channel and marketed specifically for this pur-ose (OTSC Twin Grasper® or OTSC Anchor®). Made ofighly elastic nitinol, biocompatible and easily delivered,his new device is remarkable and its full potential to help

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ndoscopists and surgeons get out of a jam and has yet to beealized. The success described in the closure of acute per-orations is explained by the fact that margins of the defectre commonly flexible and elastic to allow approximationy simply sucking them in the cup or, in larger leaks, byrasping them, avoiding laceration.9 On the other hand, dif-culties may arise in the treatment of chronic leaks, whichre surrounded by hardened and inelastic tissues unfit to bepproached. Indeed, Kirschniak15 and Albert26 have reportedhat the success rate of OTSC is inversely proportional to theime from diagnosis of the clinical leakage to the applicationf the clip, ranging from 100% after 1 week to less than 60%ith increasing time.

Our series demonstrates the capacities and limitationsf OTSC system. Although OTSC application was technicallyuccessful in all patients, we experienced one patient withstula recurrence within a few days (patient 4). However,hen referred to our department, this patient had a chronicsophago-bronchial fistula, with two small holes identifiedn the middle esophagus. The attempt to place the OTS clipas hampered by the presence of fibrotic tissue, inelastic,nd unfit to be sucked to the cup. Despite immediate clin-cal success with apparent fistula closure after the OTSCelease (clip was present, but with no contrast leak), tenays after the patient presented with recurrent respiratoryymptoms, no visualization of the clip and fistula mainte-ance. This long-term clinical failure is probably explainabley the small amount of tissue between the OTSC jaws,onsequence of tissue fibrosis. In patient 5, while thereas esophageal-pleural fistula, better margins traction waschieved allowing the correct release of the OTSC and con-equent closure of fistula. Closure of the blind jejunal loopehiscence was performed by a particular technique not yetescribed. Due to inability to directly access the fistulousrifice, we held circumferential aspiration of healthy tis-ue (without traction) located about 2 cm upstream of therifice, with subsequent release of the OTSC.19 The aimf this approach was to create an endoscopic closure ofhe loop, using healthy tissue proximal to dehiscence andhereby excluding it from luminal contact. The possibilityf complete luminal closure used deliberately in this caseas been described as an adverse effect in two cases ofseries published in 2012.18 In two other cases, successas achieved by releasing the clip on the surgical leak,ith consequent clinical improvement and completely reso-

ution of the wall defect. In the last patient OTSC placementas achieved in an iatrogenic perforation of the colon in

he context of a mucosal resection, thus avoiding surgicalpproach. The five successfully treated patients had fastecovery and started oral ingestion with no further treat-ent.In our series there were no immediate or late

omplications associated with OTSC placement, but is clearhat there was a learning curve when using this devicend associated accessories. Some severe adverse eventsre described in the literature, such as complete lumenlosure secondary to clip misplacement.18 Other possibleomplications include mucosal damage caused by the teeth

f the OTSC protruding out of the hood top during inser-ion. Therefore, special care should be taken when the OTSCs inserted into physiologically narrow sites, such as thesophageal entrance, pyloric or anal ring.27

T. Correia et al.

Although it has not been used so far in our center, OTSCas been described to be effective as hemostatic therapy.t may be of particular benefit in some cases of ulcer hem-rrhage refractory to conventional therapy and in surgicalnastomotic bleeding lesions.27

In conclusion, OTSC can be useful in the managementf gastrointestinal leaks. OTSC has several advantages overhrough-the-scope clips, allowing the closure of orifices ofarger size using a single clip. The cost of this clip is not neg-igible, though earlier hospital discharge is expected whenompared to surgery. Management of small iatrogenic orpontaneous GI perforations or leaks should involve multidis-iplinary collaboration including surgeons and endoscopists.n our opinion, endoscopic treatment should be consideredarlier in course of the disease, thus trying to prevent tissuebrosis which hampers this approach.

thical disclosures

rotection of human and animal subjects. The authorseclare that the procedures followed were in accordanceith the regulations of the relevant clinical research ethicsommittee and with those of the Code of Ethics of the Worldedical Association (Declaration of Helsinki).

onfidentiality of data. The authors declare that they haveollowed the protocols of their work center on the publica-ion of patient data and that all the patients included in thetudy received sufficient information and gave their writtennformed consent to participate in the study.

ight to privacy and informed consent. The authors havebtained the written informed consent of the patients orubjects mentioned in the article. The corresponding authors in possession of this document.

onflicts of interest

he authors have no conflicts of interest to declare.

eferences

1. Schecter WP, Hirshberg A, Chang DS, Harris HW, Napolitano LM,Wexner SD, et al. Enteric fistulas: principles of management. JAm Coll Surg. 2009;209:484---91.

2. Qadeer MA, Dumot JA, Vargo JJ, Lopez AR, Rice TW. Endoscopicclips for closing esophageal perforations: case report and pooledanalysis. Gastrointest Endosc. 2007;66:605---11.

3. Cho SB, Lee WS, Joo YE, Kim HR, Park SW, Park CH, et al. Ther-apeutic options for iatrogenic colon perforation: feasibility ofendoscopic clip closure and predictors of the need for earlysurgery. Surg Endosc. 2012;26:473---9.

4. Magdeburg R, Collet P, Post S. Endoclipping of iatrogenic colonicperforation to avoid surgery. Surg Endosc. 2008;22:1500---4.

5. Will U, Meyer F, Hartmeier S, Schramm H, Bosseckert H.Endoscopic treatment of a pseudocystocolonic fistula by bandligation and endoloop application: case report. GastrointestEndosc. 2004;59:581---3.

6. Rabago LR, Ventosa N, Castro JL, Marco J, Herrera N, Gea F.Endoscopic treatment of postoperative fistulas resistant to con-servative management using biological fibrin glue. Endoscopy.2002;34:632---8.

1

1

2

2

2

2

2

2

2

Endoscopic management of digestive leaks

7. Disibeyaz S, Parlak E, Koksal AS, Cicek B, Koc U, Sahin B.Endoscopic treatment of a large upper gastrointestinal anasto-motic leak using a prolene plug and cyanoacrylate. Endoscopy.2005;37:1032---3.

8. Endo M, Inomata M, Terni T, Oana S, Kudara N, Obara H, et al.New endoscopic technique to close large mucosal defects afterendoscopic mucosal resection in patients with gastric mucosaltumors. Dig Endosc. 2004;16:372---5.

9. Kirschniak A, Kratt T, Stüker T, Braun A, Schurr MO, KönigsrainerA. A new endoscopic over-the-scope clip system for treatmentof lesions and bleeding in GI tract: first clinical experiences.Gastrointest Endosc. 2007;66:162---7.

10. Repici A, Arezzo A, De Caro G, Morino M, Pagano N, Rando G,et al. Clinical experience with a new endoscopic over-the-scopeclip system for use in the GI tract. Dig Liver Dis. 2009;41:406---10.

11. Seebach L, Bauerfeind P, Gubler C. Sparing the surgeon: clin-ical experience with over-the-scope clips for gastrointestinalperforation. Endoscopy. 2010;42:1108---11.

12. Parodi A, Repici A, Pedroni A, Blanchi S, Conio M. Endoscopicmanagement of GI perforations with a new over-the-scope clipdevice. Gastrointest Endosc. 2010;72:881---6.

13. Renteln D, Denzer UW, Schachschal G, Anders M, Groth S, RöschT. Endoscopic closure of GI fistulae by using an over-the-scopeclip. Gastrointest Endosc. 2010;72:1289---96.

14. Manta R, Manno M, Bertani H, et al. Endoscopic treatmentof gastrointestinal fistulas using an over-the-scope clip (OTSC)device: case series from a tertiary referral center. Endoscopy.2011;43:545---8.

15. Kirschniak A, Subotova N, Zieker D, Königsrainer A, Kratt T.The over-the-scope clip for the treatment of gastrointesti-nal bleeding, perforations, and fistulas. Surg Endosc. 2011;25:2901---5.

16. Pohl J, Borgulya M, Lorenz D, Ell C. Endoscopic closure of post-

operative esophageal leaks with a novel over-the-scope clipsystem. Endoscopy. 2010;42:757---9.

17. Surace M, Mercky P, Demarkuay JF, Gonzalez JM, Dumas R,Ah-Soune P, et al. Endoscopic management of GI fistulae

2

191

with the over-the-scope clip system. Gastrointest Endosc.2011;74:1416---9.

8. Baron TH, Song LM, Ross A, Tokar JL, Irani S, Kozarek RA. Useof an over-the-scope clipping device: multicenter retrospectiveresults of the first U.S. experience (with videos). GastrointestEndosc. 2012;76:202---8.

9. Correia T, Amaro P, Sofia C. Tratamento de deiscência cirúrgicagrave com sistema Over-the-scope clip. GE - J Port Gastrenterol.2013;20:261---5.

0. Hyman NH. Managing anastomotic leaks from intestinal anasto-moses. Surgeon. 2009;7:31---5.

1. Iqbal CW, Cullinane DC, Schiller HJ, Sawyer MD, ZietlowSP, Farley DR. Surgical management and outcomes of 165colonoscopic perforations from a single institution. Arch Surg.2008;143:701---6.

2. Araujo SE, Seid VE, Caravatto PP, Dumarco R. Incidence andmanagement of colonoscopic colon perforations: 10 years expe-rience. Hepato-gastroenterol. 2009;56:1633---6.

3. Kantsevoy SV, Adler DG, Conway JD, Diehl DL, Farraye FA, KwonR, et al. Endoscopic mucosal resection and endoscopic submu-cosal dissection. Gastrointest Endosc. 2008;68:11---8.

4. Mangiavillano B, Viaggi P, Masci E. Endoscopic closure ofacute iatrogenic perforations during diagnostic and therapeu-tic endoscopy in the gastrointestinal tract using metallic clips:a literature review. J Dig Dis. 2010;11:12---8.

5. Feith M, Gillen S, Schuster T, Theisen J, Friess H, Gertler R.Healing occurs in most patients that receive endoscopic stentsfor anastomotic leakage; dislocation remains a problem. ClinGastroenterol Hepatol. 2011;9:202---10.

6. Albert JG, Friedrich-Rust M, Woeste G, Strey C, BechsteinWO, Zeuzem S, et al. Benefit of a clipping device in use inintestinal bleeding and intestinal leakage. Gastrointest Endosc.2011;74:389---97.

7. Nishiyama N, Mori H, Kobara H, Rafiq K, Fujihara S, KobayashiM, et al. Efficacy and safety of over-the-scope clip: includingcomplications after endoscopic submucosal dissection. World JGastroenterol. 2013;19:2752---60.