Scientific letter
Endoscopic management of non-iatrogenic gastrointestinal perforations – A case series
Manejo endoscópico de perforaciones gastrointestinales no iatrogénicas
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"carlosdpfernandes@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Rolando" "apellidos" => "Pinho" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Iolanda" "apellidos" => "Ribeiro" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Joana" "apellidos" => "Silva" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 4 => array:3 [ "nombre" => "Ana" "apellidos" => "Ponte" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 5 => array:3 [ "nombre" => "Sílvio" "apellidos" => "Vale" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 6 => array:3 [ "nombre" => "Jorge" "apellidos" => "Maciel" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 7 => array:3 [ "nombre" => "João" "apellidos" => "Carvalho" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Department of Gastroenterology, Centro Hospitalar de Vila Nova de Gaia, Vila Nova Gaia, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Surgery, Centro Hospitalar de Vila Nova de Gaia, Vila Nova Gaia, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Manejo endoscópico de perforaciones gastrointestinales no iatrogénicas" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 773 "Ancho" => 950 "Tamanyo" => 84323 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Computed tomography revealing a fishbone located transversally between the right branch of the pulmonary artery and descendent aorta, at about 6<span class="elsevierStyleHsp" style=""></span>mm of each vessel.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Gastrointestinal perforation is often considered a complication of endoscopic procedures. Nevertheless, non-iatrogenic perforations may also occur and their management is frequently challenging. Data about the management of non-iatrogenic gastrointestinal perforations are still scarce.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 74 years-old female was referred to the emergency department with thoracic pain after esophageal fishbone impaction. Diagnosis was made by an upper digestive endoscopy performed in an outpatient basis. No fever or other symptoms were present. Cervical-thoracic computed tomography (CT) revealed a 34<span class="elsevierStyleHsp" style=""></span>mm fishbone located transversally between the right branch of the pulmonary artery and descendent aorta, at about 6<span class="elsevierStyleHsp" style=""></span>mm of each vessel (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). After a multidisciplinary discussion, an endoscopic therapeutic approach was proposed. An upper digestive endoscopy revealed a V-shaped fishbone penetrating the esophageal wall in contralateral points. With the use of an <span class="elsevierStyleItalic">overtube</span>, the foreign body was endoscopically removed by a foreign body forceps. Endoscopic revaluation revealed two contralateral perforations. A totally covered self-expandable metallic stent (SEMS) – Hanarostent CCC 20<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>110<span class="elsevierStyleHsp" style=""></span>mm was then placed over the referred perforations. The patient remained hospitalized during 2 weeks, with a favorable evolution. The SEMS was then removed one month later, revealing complete closure of the referred perforations.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">A 69 years-old female was referred to the emergency department with a strong post-prandial epigastric pain lasting for about 1<span class="elsevierStyleHsp" style=""></span>h. A thoracic CT revealed an esophageal perforation with a massive pneumomediastinum. After a multidisciplinary discussion a therapeutic upper endoscopy was proposed. It confirmed a 5<span class="elsevierStyleHsp" style=""></span>cm wide esophageal perforation through which a large amount of food was seen in mediastinum (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). A <span class="elsevierStyleItalic">two-step</span> approach was then decided: a surgical drainage was performed and then a totally covered SEMS (Hanarostent CCC 20<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>140<span class="elsevierStyleHsp" style=""></span>mm) was placed over the referred perforation. The patient remained hospitalized for 10 days, with a favorable evolution. The SEMS was easily removed six weeks later. Complete healing of the laceration was observed.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">A 67 years-old female was referred to the emergency department with an intense constant abdominal pain lasting for about 24<span class="elsevierStyleHsp" style=""></span>h. No fever, chills or others symptoms were present. CT revealed sigmoid wall thickening with an apparent foreign body (bone) and an adjacent gas collection with 22<span class="elsevierStyleHsp" style=""></span>mm. After discussion, a therapeutic colonoscopy was performed. A foreign body (bone) penetrating the colonic wall was seen and removed with a foreign body forceps. The point of bowel perforation was not identified in the endoscopic re-evaluation. The patient was treated with NPO and empiric antibiotics. She was discharged about 2 weeks later, with no complications.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Gastrointestinal perforation consists in a rupture of the gastrointestinal tract wall. Although this condition may be readily recognized, it is not always evident. This is particularly relevant for non-iatrogenic perforations. An early diagnosis allows a prompt and optimal management.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The management of gastrointestinal perforation is often challenging and complicated. Nevertheless, some aspects may be globally considered.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Broad-spectrum antibiotics, intravenous hydration and nothing per mouth are regularly considered in gastrointestinal perforations. Nasogastric or nasojejunal tube placement is recommended in gastric, duodenal and proximal small-bowels perforations.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">1</span></a> This conservative approach is commonly considered an adjunctive therapy. Surgical repair has been considered the gold standard in the management of gastrointestinal perforations. Nevertheless, this approach carries a significant morbidity and mortality. Endoscopic management of gastrointestinal perforations is being increasingly adopted in clinical practice. The latter is also deemed as an adjunctive therapy for a surgical approach.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Currently, there are some possibilities for endoscopic management of gastrointestinal perforations, which may be used in iatrogenic and non-iatrogenic perforations. Factors like the location, dimension, duration and etiology of the gastrointestinal perforation influence the selection of the method.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Recently, self-expandable metallic stent (SEMS) became a popular option in the management of gastrointestinal perforations. Although it may be used in other locations, it is mostly used in the esophagus. Fully covered SEMS, partially covered SEMS and plastic stents have similar efficacy for the management of benign esophageal perforations.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a> In the esophagus, SEMS applicability and clinical success are very high. Its complication rate is substantial but it is associated with a very low stent-related mortality.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">2</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Through-the-scope (TTS) clips have an established role in the management of gastrointestinal perforations.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> TTS clips are frequently used in gastrointestinal perforations with a high applicability and acceptable outcomes.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">4,5</span></a> Nevertheless, TTS clips were not designed for gastrointestinal closure and their ability to perform a convenient transmural sealing is still debated. The over-the-scope-clip (OTSC Ovesco<span class="elsevierStyleSup">®</span>) has revealed good results in the management of gastrointestinal perforations.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">6,7</span></a> Considering its dimensions and design, it is considered to provide a better sealing quality, comparable to a manual surgical suture.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">7</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">Other endoscopic techniques, namely the omental patch method, suturing and stapler devices and biological glues have also been described for the management of gastrointestinal perforations.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">8</span></a> Nevertheless, more data are still needed.</p><p id="par0060" class="elsevierStylePara elsevierViewall">Non-iatrogenic gastrointestinal perforations are a feared condition in clinical practice. Their management should be discussed in a multidisciplinary basis and a conservative, endoscopic and/or surgical approach is possible. The need of a high level of expertise and specific devices are the major limitations for an endoscopic approach.</p><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0065" class="elsevierStylePara elsevierViewall">Nothing to declare.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interest</span><p id="par0070" class="elsevierStylePara elsevierViewall">Nothing to declare to all the authors.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interest" ] 2 => array:2 [ "identificador" => "xack209817" "titulo" => "Acknowledgments" ] 3 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 773 "Ancho" => 950 "Tamanyo" => 84323 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Computed tomography revealing a fishbone located transversally between the right branch of the pulmonary artery and descendent aorta, at about 6<span class="elsevierStyleHsp" style=""></span>mm of each vessel.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 772 "Ancho" => 900 "Tamanyo" => 98744 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A 5<span class="elsevierStyleHsp" style=""></span>cm wide esophageal perforation with a large amount of food in the mediastinum.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0045" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A comprehensive approach to the management of acute endoscopic perforations (with videos)" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "T.H. 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Maple" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.gie.2012.02.028" "Revista" => array:6 [ "tituloSerie" => "Gastrointest Endosc" "fecha" => "2012" "volumen" => "76" "paginaInicial" => "244" "paginaFinal" => "251" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22658920" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack209817" "titulo" => "Acknowledgments" "texto" => "<p id="par0075" class="elsevierStylePara elsevierViewall">Nothing to declare.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/24443824/0000003900000003/v1_201603290247/S2444382416000389/v1_201603290247/en/main.assets" "Apartado" => array:4 [ "identificador" => "49763" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Scientiffic letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/24443824/0000003900000003/v1_201603290247/S2444382416000389/v1_201603290247/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2444382416000389?idApp=UINPBA00004N" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 5 | 4 | 9 |
| 2024 September | 8 | 6 | 14 |
| 2024 August | 28 | 8 | 36 |
| 2024 July | 17 | 8 | 25 |
| 2024 June | 4 | 8 | 12 |
| 2024 May | 13 | 8 | 21 |
| 2024 April | 11 | 6 | 17 |
| 2024 March | 12 | 5 | 17 |
| 2024 February | 19 | 2 | 21 |
| 2024 January | 8 | 2 | 10 |
| 2023 December | 6 | 5 | 11 |
| 2023 November | 7 | 11 | 18 |
| 2023 October | 12 | 1 | 13 |
| 2023 September | 10 | 3 | 13 |
| 2023 August | 7 | 7 | 14 |
| 2023 July | 7 | 7 | 14 |
| 2023 June | 11 | 0 | 11 |
| 2023 May | 12 | 2 | 14 |
| 2023 April | 20 | 2 | 22 |
| 2023 March | 33 | 4 | 37 |
| 2023 February | 17 | 2 | 19 |
| 2023 January | 22 | 3 | 25 |
| 2022 December | 22 | 11 | 33 |
| 2022 November | 12 | 13 | 25 |
| 2022 October | 17 | 19 | 36 |
| 2022 September | 21 | 15 | 36 |
| 2022 August | 13 | 10 | 23 |
| 2022 July | 25 | 6 | 31 |
| 2022 June | 16 | 6 | 22 |
| 2022 May | 20 | 6 | 26 |
| 2022 April | 27 | 11 | 38 |
| 2022 March | 48 | 5 | 53 |
| 2022 February | 54 | 4 | 58 |
| 2022 January | 38 | 5 | 43 |
| 2021 December | 24 | 9 | 33 |
| 2021 November | 28 | 6 | 34 |
| 2021 October | 51 | 11 | 62 |
| 2021 September | 25 | 7 | 32 |
| 2021 August | 17 | 4 | 21 |
| 2021 July | 15 | 7 | 22 |
| 2021 June | 12 | 6 | 18 |
| 2021 May | 21 | 8 | 29 |
| 2021 April | 17 | 8 | 25 |
| 2021 March | 10 | 7 | 17 |
| 2021 February | 17 | 7 | 24 |
| 2021 January | 9 | 9 | 18 |
| 2020 December | 8 | 12 | 20 |
| 2020 November | 14 | 6 | 20 |
| 2020 October | 10 | 9 | 19 |
| 2020 September | 6 | 9 | 15 |
| 2020 August | 9 | 7 | 16 |
| 2020 July | 13 | 10 | 23 |
| 2020 June | 6 | 8 | 14 |
| 2020 May | 14 | 9 | 23 |
| 2020 April | 11 | 4 | 15 |
| 2020 March | 21 | 4 | 25 |
| 2020 February | 11 | 8 | 19 |
| 2020 January | 14 | 4 | 18 |
| 2019 December | 16 | 10 | 26 |
| 2019 November | 10 | 7 | 17 |
| 2019 October | 11 | 1 | 12 |
| 2019 September | 25 | 3 | 28 |
| 2019 August | 16 | 3 | 19 |
| 2019 July | 12 | 11 | 23 |
| 2019 June | 25 | 11 | 36 |
| 2019 May | 49 | 18 | 67 |
| 2019 April | 6 | 4 | 10 |
| 2019 March | 8 | 2 | 10 |
| 2019 February | 4 | 8 | 12 |
| 2019 January | 3 | 3 | 6 |
| 2018 December | 5 | 2 | 7 |
| 2018 November | 8 | 5 | 13 |
| 2018 October | 4 | 6 | 10 |
| 2018 September | 5 | 2 | 7 |
| 2018 August | 5 | 0 | 5 |
| 2018 July | 5 | 0 | 5 |
| 2018 June | 3 | 1 | 4 |
| 2018 May | 2 | 0 | 2 |
| 2018 April | 4 | 0 | 4 |
| 2018 March | 10 | 0 | 10 |
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