Greetings, ladies and gentlemen. My name is Raju. I'm from the University of Texas MD Anderson Cancer Center. On behalf of my colleagues, I would like to invite you to watch this video, a primer on endoscopic management of gastrointestinal perforations and leaks. We hope that this video would be useful in your endoscopic practice. We appreciate your feedback and we want to thank you. Dr. Nipsu Hendra's group reported the first endoscopic closure of a perforation using metallic clips after snare excision of a gastric leomyoma. We have the distinct privilege of sharing their case with you. Here is of this lesion. Snare excision was performed. Notice the small perforation at the base of the resection site. This was successfully closed with the use of three metallic clips. Subsequently, the patient was admitted to the hospital, kept nil by mouth, treated with intravenous antibiotics and intravenous anti-secretory therapy. After a few days, the patient was discharged from the hospital. The patient made an uneventful recovery without the need for surgery. Notice the excellent healing with a clean scar at six weeks. This case of endoscopic closure of gastric perforation by Dr. Nipsu Hendra's group is the beginning of a new era in endoscopy and endoluminal surgery. Currently available clips in the market include Quick Clip from Olympus, Resolution Clip from Boston Scientific, Tri-Clip from Wilson Cook. In this video, we would like to show you how to use each of these devices. Let's look at how to use Quick Clip 2 first. Remove the red stopper, followed by gently pulling the yellow cylinder back to expose the clip, and subsequently pulling slowly the slider to maximally open the clip. And in order to deploy the clip, the cylinder should be pulled back very quickly and reopened in order to close the clip and deploy it in one single action. Now, let's look at how to use a Tri-Clip device. The first step is removal of the wrapping around the fragile Tri-Clip. The Tri-Clip comes in a wrapper. This needs to be removed. And once the wrapper is removed, the Tri-Clip needs to be enclosed into the sheet by pushing the sheet over the Tri-Clip as shown here. Once this is ready, insert the clip into the endoscope, and once you see this clip outside the scope, pull the sheet back to expose the Tri-Clip. Anchor the sheet to the handle by screwing it, and then remove the Tri-Clip stopper, followed by gently pushing the grip forwards to tighten the clip as shown here. Once the device is ready, clip deployment consists of simple forward movement of the grip, followed by backward movement as shown in the next step. Now, let's look at how to use a resolution clip. The first step consists of removal of the red stopper, followed by gently pulling back the blue over sheet grip to expose the clip. This comes out as a closed clip. Opening, closing, and reopening the hand gently opens, closes, and reopens the clip multiple times. Clip deployment involves a quick, swift closure of the hand to deploy the clip very quickly and release it. One of the advantages of this clip is its ability to reopen so that one could provide a better tissue approximation if the first attempt at closing the defect is not satisfactory. One of the problems with the deployment of this clip with the sheet on is the limited amount of space in the channel of a diagnostic scope. This could be overcome by removing the sheet and inserting the naked device without the sheet on, thus allowing enough space in the channel to provide suction and also help rotate the clip. Here is what we do. After removing the red stopper, the plastic sheet is completely removed, and the naked clip is gently inserted through the biopsy port. And once it is in the field of view, one could rotate the clip as shown here for better angulation. Let us look at the animal data on endoluminal closure of esophageal, gastric, and colon perforation closure. Initially, pilot studies and subsequently randomized control studies were undertaken. We have focused our attention on developing techniques for endoluminal closure of colon perforations, starting with small tears, subsequently long tears, gaping tears, and finally holes were closed. Let's look at small perforation closure. Using pigs as the animal model, a small tear was created or a perforation was created 20 centimeters above the anal canal. As you can watch, the perforation is being successfully closed with the application of metallic clips, starting at the top end of the perforation and slowly working our way down. Immediately after perforation closure, you can see slight serosal gap while mucosa was approximated, and at one week, excellent healing on the mucosal and serosal side, and a nice histological picture of the closure. How about a placebo-controlled trial? Here, the animals were randomized to closure versus no closure. In the no-closure group, the animals were carefully followed by an independent veterinarian. Interestingly, there were no signs of peritonitis in both groups on clinical examination, but two weeks after the experimental study comparing closure with no closure, there was a remarkable difference on necropsy. As you can see here, there was a lot of peritonitis and adhesions in the placebo group compared to the clean peritoneal cavity in the closed group. How about creating a leak-proof sealing, similar to what the surgeons could achieve when closing perforations? A five to seven centimeter perforation was created in the study. Here is a seven centimeter perforation at 20 centimeters from the anal canal in the pig colon being closed with metallic clips. Initially, 10 clips were used to close this seven centimeter perforation. Subsequently, an additional 10 clips were used in order to achieve a complete leak-proof sealing of the entire perforation site. Here, you can watch the second set of clips being applied at less than zero to 0.5 centimeter distance. Here is the final view of a seven centimeter perforation closed with 20 clips and on necropsy and on leak test. There was no leakage of dye at all. How about closing circular holes? The technique of circular hole closure is slightly different. You approach from the bottom to the top and approximate the lower edge to the top edge as shown here. It is important to keep the clip very close to the scope and move the clip and the scope as a single unit. Start at one edge and work your way to the other edge. It's important to be absolutely sure that both edges were approximated. Here is a leak that following longitudinal closure, but with transverse closure, there was no leakage of dye at all. This is what should be done. Next, how about closing gaping tears or gaping perforations? Here, you apply T-tags on either side of the perforation and approximate the edges together. These types of gaping tears are difficult to close with clips. In such cases, suturing unit could be used. As shown here, you apply a T-tag on either side of the perforation and bring the edges together and approximate them. Again, the procedure is repeated until closure. Notice the excellent clean peritoneal cavity, an adhesion and a T-tag and a negative leak test at two weeks. In summary, we have shown that endoluminal closure of colon perforations is feasible, technically successful, prevents peritonitis and limits adhesions compared to surgery. Within seconds after any gastrointestinal perforation, air leaks out into the peritoneal cavity or into the mediastinum resulting in a tension pneumoperitoneum or a pneumothorax with massive air leak. If unattended, this could result in a cold situation with pulseless electrical activity. This is an emergency and requires immediate decompression to relieve the tension pneumoperitoneum and pneumothorax. The perforation needs to be closed and the patient needs to be put on parental antibiotics and closely observed until full recovery. If the perforation goes unattended immediately, within the next few minutes to hours fluid from the lumen escapes into the peritoneal and mediastinal cavities, setting up a process for peritonitis and mediastinitis. Once this sets in, the principles of management include drainage and clearance of the infection, closure of the perforation site, broad spectrum intravenous antibiotics and nutritional support until the patient makes a full complete recovery. Surgery has been the mainstay of treatment for all gastrointestinal perforations including those following endoscopy. There are some disadvantages to this approach. Surgery may not be available. One may need to wait for an operating room to open. The patient needs to undergo general anesthesia, either a thoracotomy or a laparotomy followed by dissection to find the perforation before it could be repaired or diverted. Using this approach, there is a significant amount of morbidity and mortality, especially in the elderly and in the frail. How about thinking about a change in the paradigm from surgery to endoluminal closure of gastrointestinal perforations as these perforations following endoscopy are readily visible during endoscopy. By this approach, one could avoid the need for general anesthesia, the need for additional thoracotomy or laparotomy, followed by dissection to find the perforation as it is readily obvious for immediate repair or diversion. A number of devices are currently available for endoscopic closure. These could be classified as closing devices consisting of clips, key tags, stitching devices, and staplers, bypass devices in the form of stents, and finally fillers to fill the defect with various types of glues and tissue grafts. How about closing devices and how do these devices close perforations compared to surgery? Surgeons have typically used what we describe as a parallel closure method, layer by layer. In contrast, when you use endoclips, it results in an inverted closure. With the use of key tags, it results in an everted closure. Irrespective of the method of closure, parallel closure, inverted closure, and everted closure result in excellent healing of perforations in animal studies. When it comes to burst pressures immediately after closure, only inverted closure with clips is comparable to surgical parallel closure. Now let's look at what are the different techniques of clip closure. Small tears, long tears, gaping tears, and holes. Both small and long non-gaping tears can be successfully closed with clips as the open clip can bridge that non-gaping gap. Gaping tears require a special suturing device, while holes require a special technique of closure with clips. Let's look at a video demonstration of clip closure of a linear perforation from top to down as the scope is withdrawn from the top edge of the perforation to the bottom edge. With holes, the technique is approaching it from below upwards from left to right as shown in this video with the application of the first clip that makes subsequent clip application much easier. Coming to the abdominal decompression, it's important to be done immediately when you notice tension pneumoperitoneum or pneumothorax with the use of a small bore needle followed by a large bore needle to decompress the abdomen. Now let us look at the evidence regarding the role of endoluminal closure of gastrointestinal perforations. Both pilot studies and randomized control studies comparing endoluminal closure with surgery have looked at esophageal, gastric, and colon perforations. A number of different investigators from this country and abroad have undertaken these investigations. The results could be summarized as endoluminal closure is technically feasible and successful in healing perforations, preventing peritonitis, and compared to surgery limiting the amount of peritoneal adhesions. In addition, clinical evidence in the form of case reports and case studies on the benefits of endoluminal closure of esophageal, gastric, and colon perforations is appearing in the literature. Next, let us look at how to manage chronic fistulas. The most important principle involves drainage to clear the infection followed by closure with one of the devices that we have talked about. When it comes to drainage, one could use nasal esophageal mediastinal drain by inserting a catheter over a wire into the mediastinum and using it to flush and clear liquid, debris, and pus. When it comes to large amounts of necrotic material that is not liquidy, one could use endoscopic debridement similar to the one that we have been using for the management of infected pancreatic necrosis. One could also consider the use of leaving a catheter with the sponge at the end of it for suction, otherwise known as endosponge suction. Irrespective of the method of drainage, once the infected material is removed and the cavity is cleaned with excellent granulation tissue, for large fistulas, a stent is the best option. For small fistulas without everted edges, clip closure. In some cases, T-tags have been used for closure. Secondary intention has also been reported to be successful. Application of glue is another option that could be considered. Regarding glues and grafts, fibrin glues are widely utilized in the United States, acrylates in Europe, and for large defects, grafts could be utilized. In summary, acute perforations, the management involves immediate closure and decompression to relieve any tension pneumoperitoneum or pneumothorax. For chronic fistulas, drainage, clearance of the infection, followed by closure. In this chapter, we would like to show you endoscopic management of different types of esophageal leaks. In the literature, endoluminal closure has been shown to be successful in the management of perforations following endoscopic dilation, mucosal resection, endoscopic submucosal dissection, and those following endoscope insertion. In addition, it's been shown to be successful in the management of Boerhof syndrome, post-operative leaks, and those following foreign body ingestion. Lift and cut EMR perforation closure. In this case of squamous high-grade dysplasia, a lift and cut endoscopic mucosal resection was performed and the lesion was removed in a piecemeal fashion. During the second resection, after injection of additional amounts of saline and indigo carmine, a lift and cut technique using a snare and a grasping forceps was performed. Notice the deep mucosal resection and a perforation at its base. This perforation was closed immediately with clips starting at the top of the perforation. Radiological conformation of the perforation will waste time and lose the precious opportunity for successful endoluminal closure. As you notice, both the perforation and the mucosal defect were completely closed using endoluminal clip closure. Another example of esophageal perforation following band ligation, endoscopic mucosal resection of Barrett's esophagus, complicated by high-grade dysplasia. The snare was utilized to resect the lesion below the band. As one notices, following the resection, a one centimeter perforation was noted. Immediately, the scope was passed and all the bands were released in the stomach. This provided a better view, allowing the edges of the perforation to be suctioned into an open clip awaiting in the cap. After successful approximation of the edges of the perforation with the clips, cyanoacrylate glue was sprayed to create an airtight seal. There was no pneumo-mediastinum in the post-operative period and the patient was allowed clear liquids 24 hours later. Three days later, you see granulation tissue and endoscopic mucosal resection of the remaining area of Barrett's high-grade dysplasia was undertaken. Next is an example of balloon dilation esophageal perforation. Here is a tight, lower esophageal stricture complicating radiotherapy for GE junction cancer. These strictures are at a higher risk for esophageal perforation. Following dilation, a small tear was noted as shown here. This is difficult to close with clips due to extensive scarring. In such cases, esophageal perforations occurring in the setting of an esophageal stricture, stent placement will be the best option. Pneumo-mediastinum was seen, but the patient was asymptomatic. Next is an example of esophageal perforation complicating pneumatic balloon dilation of achalacea cardia. This can occur in 5% of the dilations. These perforations tend to be long and linear and some of them may be complicated by some amount of bleeding. Linear application of a series of clips starting at the top end of the perforation that is close to the GE junction and moving back would be successful. However, such long perforations may benefit from the application of a stent instead of clips. Use of a cap at the end of the scope in these difficult perforation closures may be beneficial as the cap allows to open up the operating field for a better view and better application of the clips. Here is another example of an overtube related esophageal perforation. Notice the large perforation and the mediastinal structures. Such perforations are better managed with the insertion of an esophageal stent. Initially, an attempt was made to close the perforation with clips using a cap at the end of the scope to facilitate a better view and opening up of the operating field. After the application of a series of clips, histoacryl glue was sprayed to create an airtight seal. However, a couple of days later following a coughing episode, there was dehiscence of the wound. Next is an example of endoscopic ultrasound scope-induced perforation after examination of the mid-esophageal cancer. Such cases, there is no role for clip closure, and these cases are best managed by immediate insertion of a self-expanding stent. Following the insertion of the stent, the patient had mild chest pain, minimal pneumo-mediastinum, and without any clinical features of mediastinitis. Subsequently, a barium swallow 24 hours later confirmed sealing of the perforation. These stents could be removed after 6 to 12 weeks. In this patient, the stent was removed after completion of chemoradiation. Next is an example of a postoperative esophageal fistula complicating thoracic aneurysm repair. In the first step, we cleared the infection in the mediastinum by entering the mediastinum through the esophagus and fistulas opening. After suctioning the debris, saline was flushed to loosen up any material and allowing further clearance. Subsequently, a naso-mediastinal catheter was inserted through the esophagus and this was used for repeated flushing, drainage, and clearance of the infection till pink granulation tissue was seen. After this clearance of the infection, a self-expanding plastic esophageal stent was inserted across the fissula. Twenty-four hours later, barium swallow confirmed sealing of the leak. After eight weeks, the plastic self-expanding stent was successfully removed with the grasping forceps. Examination of the fissula revealed marked reduction in the size of the lumen. This was treated with cautery, followed by the application of clips. Despite the cautery, the clip application to close the fissula was unsuccessful because of the fibrotic nature of the opening. The clips were removed and another attempt was made to close the fissula by the insertion of a second plastic stent. After eight weeks, the plastic stent was removed successfully and the esophagus was examined to ensure complete healing of the fissula. Here is the well-healed scar. Here is an example of a spontaneous esophageal rupture that was initially managed by surgical closure, which failed. As you can see here, there is a large defect with everted edges and sutures in the underlying area. This type of defect cannot be closed with clips, especially with the everted edges. Stent insertion, either a self-expanding plastic or a self-expanding metal stent, is the best option in this case. One should be careful with these stents as they tend to migrate in a high percentage. Another example of a post-operative fissula. This is a case of an esophageal leak occurring after epiphrenic diverticulectomy. Notice the large defect with staples and underlying infection in the mediastinum from dehiscence of the staples. Again, this is best managed by the insertion of a self-expanding plastic stent. One should be careful as these stents tend to migrate. A migration rate of 30% to 40% has been reported in the literature. This is another case of a refractory esophageal cutaneous fissula following esophageal gastrectomy. That has failed to close despite multiple endoscopic stent insertions and cyanoacrylate glue injections. Notice the fissula here that is first treated with APC or organ plasma coagulation, which is utilized to cauterize the edges or roughening up the edges of the fissula. And once this is done, glue is injected to seal this fissula. As you can see here, the fissula opening has been nicely cauterized. After that, the scope is removed and a snare is inserted to the biopsy channel. And the catheter that is used for deploying the glue is ensnared along the side of the scope and then gently dragged with the help of the snare in the channel down the throat, down the esophagus to the site of the esophageal cutaneous fissula. Subsequently, the catheter was gently inserted into the fissula site and the glue was injected. Here is fibrin sealant, which is a combination of fibrinogen and thrombin that are injected through two separate syringes to fill this cavity. As you can see, the fibrinogen polymerizes to form a firm clot. This treatment was successful in the closure of this refractory esophageal cutaneous fissula that failed multiple endoscopic interventions. This patient required a total of 50 endoscopies before this fissula was finally sealed off with the injection of fibrin glue as shown here. In this chapter, endoscopic management of gastroduvardal leaks will be presented. Gastric perforations following EMR and ESD were successfully closed with clips. In addition, duvardal perforations from EUS scope insertion, biliary sphincterotomy, migrated biliary stent, and ampullary resection were also successfully closed with clips. In this example, simple clip closure of a gastric perforation is presented. With this technique, keep the clip close to the endoscope, engage the lower edge of the perforation, and gently push it to the upper edge, followed by approximation of the both edges and subsequent clip closure. Start at one end of the perforation and work your way to the other side for a successful complete closure of the perforation. In this case, we demonstrate a two-layer closure method of gastric perforation after initial marginal cut followed by snare excision. Notice the small, less than one centimeter perforation in the center of a large resection that was first closed with the application of clips. After the closure of the deeper layers of the defect, the superficial layers were again closed in a separate layer as shown here. This two-layer closure provides additional safety in areas of the stomach where the stomach wall is rather thick. Notice the successful closure of this large defect. Next we demonstrate another technique of gastric perforation closure. Here a large perforation was closed with an omental patch clip closure technique. After suctioning of the omentum into the gastric lumen, clips were utilized to anchor the omentum to the edge of the gastric perforation. A series of clips were used for successful closure with excellent healing at six months. Air leak through a small gastric perforation can occur during endoscopic submucosal dissection, resulting in tension pneumoperitoneum. In this setting, immediate abdominal decompression should be undertaken after cleaning the abdominal wall with betadine solution. After adequate cleaning, a saline-filled syringe attached to a small-gauge needle is inserted into the peritoneal cavity to aspirate air, thus confirming the diagnosis of pneumoperitoneum. Once this is done, then a larger bore and your cath is inserted into the peritoneal cavity to allow further decompression. Once the tension pneumoperitoneum has resolved completely, endoscopy could be resumed with clip closure of the perforation, followed by endoscopic resection of the remaining lesion. In this video, we demonstrate endoscopic closure of an anastomotic fistula following sleeve gastric resection as part of the cancer surgery. Here, the fistula site was cauterized with a bicap probe to roughen it up, followed by the clip approximation of the edges of the fistula with clips. It's important to start at one end and work yourself way down, followed by the application of fibrin glue to allow a better healing. Let me summarize the results on endoluminal closure of gastric perforations by reviewing the largest experience from the National Cancer Center, Japan, where over 2,000 EMRs were performed between 1987 to 2004. Five percent of these EMRs were complicated by the development of a gastric perforation. Majority of these were closed with clips at the time of endoscopy. Of these, only two failed endoscopic closure requiring surgery, while 98 percent of them had a successful closure of the perforation. If you look at the follow-up, these patients required less than one week of hospitalization, a couple of days of IV fluids, antibiotics, and 24 hours of NG suction. Next chapter is endoscopic management of colonic leaks. Retroflexion injury of the rectum, hockey stick injury of the sigmoid colon, secal barotrauma could result in perforation of the colon. In addition, EMR, ESD, snare resection have also been reported. Finally, a number of postoperative colonic fistulas have been reported. These could be closed with endoluminal clip closure. First case, EMR perforation of the colon. Here following colonic EMR, a small perforation was noted, which was closed with a series of clips. Notice the first clip application that was applied at the top edge of the perforation, and then we worked our way down from top to bottom with the application of a series of clips. This resulted in a successful and complete closure of this colonic perforation following endoscopic mucosal resection. Next we will share with you endoscopic closure of a large perforation. Here is a large secal polyp that was removed after injection of submucosal saline. As expected, this case was complicated by a large perforation. In such cases, it is important to keep the clips ready and also to dry up the operating field to prevent escape of the fluid contents into the peritoneal cavity. One should keep an eye on the abdomen to check for signs of tension pneumoperitoneum. As one observes here, we started clip closure of this large perforation at the upper end and worked our way down to close this in a linear fashion. It's important to keep a large-bore angiocat in the endoscopy suite to do the decompression if it were to be necessary. This patient required a total of five clips for complete closure of this large perforation. Next is a case of a perforation following endoscopic submucosal dissection of a large rectal vellus adenoma. Notice the perforation here. This perforation was immediately closed with the application of clips. Notice the advantage of having a small cap, which keeps the operating field open for successful lip deployment. The next case is a role of endoluminal closure of postoperative anastomotic fistula following colon surgery. Here is the small fistula adjacent to the anastomosis. This was better seen with the use of a cap at the end of the scope. The fistula's track was cauterized with a bi-cap probe to allow better healing after approximation of the edges with clips. Immediately after closure with multiple clips, the fistula's output decreased dramatically from over 100 cc's per day to less than a few cc's. It took several weeks for the track to close and heal completely. In summary, we have shown different cases of endoluminal closure of colon perforations. In a recent article, 23 perforations complicated over 15,000 therapeutic colonoscopy procedures, 16 immediate perforations, nine of them were successfully closed by endoscopy. Practical endoscopic management of gastrointestinal perforations. This was based on a review published in the American Journal of Gastroenterology with a specific focus on endoscopic perforations. Although surgery is still the treatment of choice, we could learn a lot by closely involving our surgical colleagues in the management of these patients. Endoscopic closure can be successfully used to close perforations with a surgical backup. Training in endoscopic closure is critical for a successful outcome. A number of resources are currently available. These include reading material from the journals such as Gastrointestinal Endoscopy and Endoscopy, videos from the ASGE Learning Library and Dave Project on the web, hands-on training courses on closure arranged by the ASGE, and finally, practicing the art of clip application and training your technicians how to handle these clips like any other endoscopic device. These are critical in the management. I would like to focus on practical endoscopic management of gastrointestinal perforations, talking about how to prevent perforations, immediate endoscopic management, i.e. diagnosis, followed by closure of perforations, and subsequently, how to manage these patients in the post-operative period. Coming to prevention of endoscopic perforations, this is critical. By paying close attention to the technique of endoscope insertion and withdrawal, one could avoid perforations during diagnostic endoscopy. In patients with a stiff neck, one could avoid cervical perforation by resorting to a smaller-caliber endoscope. And in those with tight strictures, one should gauge the stricture instead of blindly pushing the scope. In those with a small rectum, retroflexion could lead to rectal perforation. In such cases, slow decompression of the rectum and examination of the rectum may suffice. In those with angulated and redundant sigmoid colon, who are at a high risk for hockey stick injury and perforation of the sigmoid colon, this could be avoided by resorting to a smaller-caliber scope or the use of a balloon-assisted endoscopy. In patients requiring prolonged intubation, sacral barotrauma could be avoided by periodically decompressing the colon using water infusion method or the use of CO2. Next, coming to the endoscopic therapy-related perforations. Caution is required during endoscopic resection. Small polyps could be removed by cold snare instead of heart biopsy polypectomy, which is associated with a higher risk of perforation. In patients with sessile and plat lesions, using a lift with submucosal saline injection followed by cut is associated with a lesser incidence of colonic perforations. In removing pedunculated polyps, keep the snare away from the colon wall and tent the polyp away from the colon wall to prevent thermal injury and related perforation. For larger polyps, try to use a piecemeal resection as the risk of thermal injury is less compared to end-block resection. And in those where you think that the risk of perforation is high, refer the patients to advanced endoscopy centers or to a surgeon where the condition could be managed in a much more controlled manner. It's important to avoid colonoscopy in a dirty colon as the risk of mortality increases in those who have a perforation in the setting of a dirty colon compared to those with a perforation occurring in the setting of a clean colon. Hence, avoid this complication by avoiding colonoscopy in a dirty colon. Next is drying up the field prior to resection. Whenever you consider resection, which is at a risk of perforation, make sure you clean up the field so as to avoid escape of fluid as you can see here. CO2 instead of room air may be beneficial as CO2 tends to get reabsorbed very quickly. This may have a role in complicated intubations and also complicated resections as one would want to have the gut decompressed immediately after the procedure to avoid barotrauma injury and also avoid loss of closure from distended colon. Here we would like to share with you images of different types of perforations encountered during endoscopy. Clipped and cut EMR perforation of the esophagus, band ligation resection complicated by perforation of the esophagus, esophageal balloon dilation complicated by perforation of the esophagus, pore tube injury and perforation of the esophagus showing the mediastinum, dehiscence of surgical closure of spontaneous esophageal perforation, dehiscence following esophageal epiphrenic diverticulectomy, EMR perforation of the stomach, EMR perforation of the stomach, ESD related perforation of the stomach, EMR perforation of the stomach with omentum visible, stapledehiscence of gastric surgery, ESD perforation of the colon, EMR perforation of the colon, EMR perforation of the colon. By showing this series of videos, we hope that you have developed an eye for recognizing different types of perforations. Regarding the consent for clip approximation, if one is experienced in the use of clips, it's important to share with patients that clips will be used to prevent perforation and also treat perforations so as to minimize the need for surgery. Coming to the closure of perforations, let's focus on how to manage esophageal perforations, the role of endoscopic therapy in the management of esophageal leaks. Patients who are too sick for surgery, patients in whom operative closure is not possible because of a delay in the diagnosis, patients with an esophageal cancer complicated by a perforation, patients with an astemotic leak, and patients with a perforation recognized during endoscopy are potential candidates for endoluminal therapy. Depending upon the nature of perforation slash fistula and coexisting pathology, small perforations of less than two centimeters with no underlying cancer and in those without a stricture, clips could be used. In those with a stricture, stent is a better option. Those with large perforations of more than two centimeters with no underlying cancer, stent is the preferred option. Those with a cancer complicated by esophageal perforation, such as those occurring during U.S., stent should be considered. In patients who have post-operative leaks, especially with those with a small post-operative leak, clip could be used for closure and in those with the larger leaks, stent is a better option. Keep a stock of different types of clips readily available in the endoscopy lab so that one may choose the most appropriate clip depending upon the type of defect that needs to be closed. Let us review the technique of closure of perforations following EMR, either in the stomach, the vardnum or colon. The technique is essentially the same. It is important to have patience when you are closing perforations with an endoscope. Keep the operating field very close to the scope. With the clip open, engage the lower edge of the perforation and gently push it to the upper edge and close it, starting at one edge of the perforation and working your way to the other side. As you can see here, the lower edge is gently being approximated to the upper edge and once the upper edge is within the grasp of the clip, the clip is deployed. It's important to have patience and it's also important to avoid misplacing the clips as it would occupy the real estate and make closure difficult. As you can see here, the perforation was successfully closed with a series of clips, starting at the lower edge and working towards the upper edge of the perforation. Coming to the post-operative management of these patients, it is important to call the surgeon as these patients should be managed combinedly with the help of surgical team. Keep the patient nail by mouth and put him on total bowel rest. Start the patient on broad spectrum intravenous antibiotics. Patient should be on intravenous fluids. In addition, in patients with esophageal perforation, it is important to keep them on intravenous acid suppressive therapy, preferably with the use of photon pump inhibitors. Keep the head end of the bed up to prevent acid reflux. One could also reduce oral secretions by using glycopyrrolate injections. Following endoluminal closure, the patient should be closely monitored until the fever, pain, signs of mediastinal or peritoneal inflammation resolve, and the blood inflammatory markers return to normal. Oral intake could be re-assumed then. In the setting of esophageal perforation, a contrast study of the esophagus is required to confirm absence of leakage before oral intake could be resumed. Surgery after clip approximation of perforations is required in those who demonstrate diffuse peritonitis and in those with localized peritonitis that tends to worsen. However, in those that tend to be asymptomatic and continue to improve after clip approximation, surgery could be totally avoided. In conclusion, iatrogenic perforations can be treated with immediate endoscopic closure. Successful management of this problem requires close collaboration between the endoscopist and the surgeon. Training and endoscopic closure techniques is critical, and we hope this video has provided you with some of the basic understanding in the management of this problem.

endoscopic management

gastrointestinal perforations

metallic clips

closure

snare excision

animal studies

endoluminal closure

tear closure techniques

chronic fistulas

post-operative management