Shah, Hiral N, MD

Shah, Shashin, MD

Sullivan, Matthew, DO

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health NetworkLVHN Scholarly WorksDepartment of MedicineClosing the Gap: Deployment of an Over-the-Scope Clip after Colonic Endoscopic MucosalResectionMatthew Sullivan DOLehigh Valley Health Network, Matthew.Sullivan@lvhn.orgShashin Shah MDLehigh Valley Health Network, Shashin.Shah@lvhn.orgHiral N. Shah MDLehigh Valley Health Network, hiral_n.shah@lvhn.orgFollow this and additional works at: http://scholarlyworks.lvhn.org/medicinePart of the Gastroenterology Commons, and the Medical Sciences CommonsThis Poster is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by anauthorized administrator. For more information, please contact LibraryServices@lvhn.org.Published In/Presented AtSullivan, M. J., Shah, S. Shah, H. N. (2016,Oct). Closing the Gap: Deployment of an Over-the-Scope Clip after Colonic Endoscopic MucosalResection. Poster Presented at: American College of Gastroenterology Annual Scientific Meeting, Las Vegas, NV.References:1. Hwang JH, Konda V, Abu Dayyeh BK, et al. Endoscopic mucosal resection. Gastrointest Endosc 2015;82(2):215-226.2.  Belderbos TD, Leenders M, Moons LM, et al. Local recurrence after endoscopic mucosal resection of nonpedunculated colorectal lesions: systematic review and meta-analysis. Endoscopy 2014;46:388-402.3.  Elmunzer, BJ. Just Clip It: Endoscopic Clipping in the 21st Century. Am J Gastroenterol 2016;111:6-8.4.  Liaquat H, Rohn E, and Rex DK. Prophylactic clip closure reduced the risk of delayed postpolypectomy hemorrhage: experience in 277 clipped large sessile or flat colorectal lesions and 247 control lesions. Gastrointest Endosc 2013;77(3):401-407.5. Jayaraman V, Hammerle C, Lo SK, et al. Clinical Application and Outcomes of Over the Scope Clip Device: Initial US Experience in Humans. Diagn Ther Endosc 2013;2013:381873.6.  Wedi E, Gonzalez S, Menke D, et al. One hundred and one over-the-scope-clip applications for severe gastrointestinal bleeding, leaks and fistulas. World J Gastroenterol 2016;22(5):1844-1853.•  Prophylactic closure of polypectomy sites to prevent delayed hemorrhage is a debated topic following a randomized controlled trial in 2003 which found no benefit from prophylactic clipping.4•  A 2013 retrospective review of prophylactic clip closure after resection of colonic lesions ≥2cm showed an association between delayed bleeding and lesions which were not clipped with an odds ratio of 6.0 (95% CI 2.0-18.5).4•  This study also demonstrated that:  –  Polyps that were not clipped were 6 times more likely to have a bleed and 4.4 times more likely to have any complication compared with polyps that were fully clipped.4  –  Increasing polyp size was significantly associated with a risk of bleeding.4  –  Proximal polyp location was two times more likely to be associated with a bleed.4  –  The mean number of clips placed in patients with any clipping was 3.7.4  –  The average charge per clip was $150.4•  One OTSC costs our institution $559.  If using more than 4 clips to close a larger defect, use of an OTSC would provide a cost benefit.•  A 2016 retrospective review of OTSC applications included 18 patients who had OTSC application to prevent secondary perforation and 12 for prevention of secondary bleeding.  All 30 patients experienced technical and clinical success.6•  Two of the 12 patients in whom an OTSC was placed for prevention of secondary bleeding had the clip applied after standard through-the-scope clips had failed.6  This was a similar scenario to our patient where standard clips broke and lead to failure of approximation of the mucosal defect.•  Due to the positioning and angulation of the defect in our patient, it was felt that a gastroscope would provide better visualization.  Remarkably, the standard gastroscope equipped with an OTSC was able to reach the ascending colon and provided the desired superior views in order to successfully place the OTSC.DISCUSSION© 2016 Lehigh Valley Health NetworkFigure 1:  Large ascending colonic defect following EMR of an 18mm sessile polyp.•  Endoscopic mucosal resection (EMR) is an endoscopic technique employed for removal of neoplasms confined to the mucosa and submucosa of the GI tract.1•  Injection-assisted EMR is commonly used for resection of large or flat lesions in the colon1 and local recurrence in this area following EMR is only 3% when removed en bloc.2•  Bleeding occurs in 2-11% of patients after EMR of large colonic polyps1 and delayed hemorrhage is the most common complication following EMR.3•  Prophylactic clipping of resection sites following EMR of large colorectal polyps has been associated with lower incidence of delayed bleeding.4•  Through-the-scope clips are limited by their smaller wingspan and low force of closure which often necessitates the placement of multiple clips for closure of large defects.5•  Newer endoscopic over-the-scope clips (OTSC) have been demonstrated to be useful for non-surgical closure of large defects5 and fistulas as well as treatment of gastrointestinal bleeding.6•  OTSCs have also been employed for prevention of secondary perforation or bleeding with excellent results.5,6A 56 year-old male with a history of polycystic kidney disease underwent initial routine screening colonoscopy which revealed three polyps including an 18mm sessile polyp in the ascending colon.  Due to the high risk of bleeding and perforation with piecemeal resection, a mucosal tattoo was placed and the patient returned for repeat colonoscopy with planned EMR of the ascending colon polyp.  The lesion was first raised using methylene blue and was then successfully removed en bloc using a braded snare.  The location of the defect was in a severely angulated position and multiple attempts were made to close the defect using traditional through-the-scope clips in order to reduce the incidence of delayed hemorrhage.  However, due to the low force of closure, several clips broke under the stress of attempting to approximate the edges of the large defect.  The colonoscope was withdrawn and a standard adult gastroscope was loaded with an 11mm cap/6mm depth over-the-scope clip.  The gastroscope successfully reached the ascending colon and was able to provide improved en face visualization compared to the colonoscope.  The over-the-scope clip was deployed resulting in a complete closure of the defect without any post-procedure bleeding or complication.Figure 2:  Broken and bent through-the-scope clips after attempted approximation of the mucosal defect.Figure 3:  Successful application of the over-the-scope clip.1Department of Internal Medicine, 2Division of Gastroenterology and Hepatology, Lehigh Valley Health Network, Allentown, PennsylvaniaClosing the Gap: Deployment of an Over-the-Scope Clip after Colonic Endoscopic Mucosal Resection1Matthew J. Sullivan, DO, 2Shashin Shah, MD and 2Hiral N. Shah, MDBACKGROUNDCASE PRESENTATION

Closing the Gap: Deployment of an Over-the-Scope Clip after Colonic Endoscopic Mucosal Resection

https://scholarlyworks.lvhn.org/cgi/viewcontent.cgi?article=2068&context=medicine

Closing the Gap: Deployment of an Over-the-Scope Clip after Colonic Endoscopic Mucosal Resection

Abstract

Similar works

Full text

Available Versions

Lehigh Valley Health Network: LVHN Scholarly Works