A novel method for endoscopic perforation management by using abdominal exploration and full-thickness sutured closure

Abstract

Background: Perforation of the GI tract during endoscopy can result in significant morbidity and mortality. Early recognition and immediate management of endoscopic perforation are essential to optimize outcome. Larger perforations, defects with complex geometry, and those complicated by leakage of luminal contents have traditionally required surgical management.

Objective: To assess the feasibility of a new method for managing complex perforations that incorporates abdominal exploration and endoscopic sutured closure.

Design: Case series.

Setting: Tertiary care center.

Patients: Two patients with large, complicated perforations and peritoneal contamination.

Interventions: Endoscopic exploration of abdomen with angiocatheter placement under direct visualization, management of leaked luminal contents, and full-thickness sutured defect closure.

Results: Endoscopic abdominal exploration through the perforation site allowed safe placement of an angiocatheter for management of pneumoperitoneum, inspection for injury that may warrant surgical management, and removal of leaked luminal contents. Endoscopic sutured closure allowed safe and robust perforation management. Repair of gastrojejunal anastomotic perforation required 2 sutures and 63 minutes. Repair of gastric perforation required 4 sutures and 48 minutes. Patients had successful endoscopic defect closure confirmed by an upper GI series and were discharged 1 day later.

Limitations: Report of a new method in 2 patients performed at tertiary care center.

Conclusions: We demonstrate successful management of complex perforations with peritoneal contamination by incorporating endoscopic exploration and sutured closure with standard treatment measures. Traditional practice would have directed these patients to surgical management, which introduces additional morbidity and cost. A means for safe and broad implementation of these techniques should be evaluated.