Endoscopic clips for closing esophageal perforations: case report and pooled analysis - 22/08/11

Doi : 10.1016/j.gie.2007.03.1028

Mohammed A. Qadeer, MD, John A. Dumot, DO ^⁎, John J. Vargo, MD, MPH, A. Rocio Lopez, MS, MPH, Thomas W. Rice, MD
Current affiliations: Departments of Gastroenterology and Hepatology (M.A.Q., J.A.D., J.J.V.), Quantitative Health Sciences (A.R.L.), Thoracic and Cardiovascular Surgery (T.W.R.), Cleveland Clinic, Cleveland, Ohio, USA

Reprint requests: John A. Dumot, DO, Section of Therapeutic Endoscopy, Department of Gastroenterology and Hepatology Cleveland Clinic, 9500 Euclid Ave, A30, Cleveland, OH 44195.

Cleveland, Ohio, USA

Abstract

Background

Acute and chronic esophageal perforations have traditionally been treated with surgery or a conservative approach. Recently, endoscopic repair has been reported in some case reports.

Objective

To describe a case of a chronic esophagoperitoneal fistula successfully closed by endoscopic clips after several failed reoperations and stent placement. To perform a pooled analysis of the reports describing such closures.

Design

Case report and pooled analysis.

Setting

Tertiary-care hospitals.

Patients

Our patient presented with mature perforation in the distal esophagus caused by laparoscopic band gastroplasty. Patients for pooled analysis identified by a MEDLINE search (1966 to January 2007) performed for all the English language articles that reported esophageal perforation/fistulae and endoscopic clips.

Interventions

Endoscopic clip application after ablation of epithelialized edges in our patient. Pooled analyses for demographic and perforation variables, along with predictors for closure time after clipping, were performed.

Main Outcome Measurements

Closure of esophageal perforations.

Results

The fistula in our patient closed in 3 weeks after endoscopic clipping. The literature review identified a total of 11 articles that describe 17 patients (acute 7, intermediate 4, and chronic 6). The most common cause was iatrogenic (65%), and the size of the perforation ranged from 3 to 25 mm. The median healing time after clipping was 18 days (interquartile range 6-26). Both univariable and multivariable analyses identified only the duration of perforation as a significant predictor of closure time, P values .003 and .02, respectively.

Limitations

Small sample size, nonrandomized sample.

Conclusions

Endoclips may be effective for closing both acute and chronic esophageal perforations. The duration of the perforation is a significant factor for predicting closure time.

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Abbreviations : EJ, ESD, GE, IQR, IV, J-feeds, JP, NK, PC, TPN