Postgraduate Course at DDW: Complete Clinical Updates for Today's Practice | May 2025-LEAKS, FISTULAS, MUCOSAL DEFECTS

Video Transcription

Video Summary

Aziz Alam (Northwestern) reviews endoscopic management of iatrogenic perforations, mucosal defects, post-surgical leaks, and fistulas. He traces the evolution from early endoscopes to modern closure tools: through-the-scope clips (best for defects <2 cm), over-the-scope nitinol clips for larger defects, and endoscopic suturing for full-thickness closure. He emphasizes clinical risk: air leaks may be manageable, but fluid/stool leakage drives peritonitis and surgery. Case examples show intentional and inadvertent perforations during ESD closed successfully with clips or suturing, often after completing resection if the patient remains stable. He highlights preparedness for tension pneumoperitoneum and demonstrates needle decompression using an angiocatheter kit.<br /><br />Data suggest ~90% overall success for acute endoscopic perforation closure, though evidence quality is limited and biased. For large mucosal defects, he demonstrates clip “anchor/divot” techniques and suturing strategies to avoid leaving dead space (“burrito effect”).<br /><br />For leaks, he outlines multimodal, multidisciplinary care (stents, clips/sutures, sealants, internal drainage, endoscopic vacuum therapy). EVAC shows higher closure than stents in intrathoracic leaks, and internal drainage with pigtail stents is highly effective in sleeve gastrectomy leaks but often requires multiple sessions. Fistulas are hardest; suturing has poor long-term success, while OTSC with tract debridement can work, especially for smaller defects.

Keywords

endoscopic closure

iatrogenic perforation

through-the-scope clips

over-the-scope clip (OTSC)

endoscopic suturing

post-surgical leaks

endoscopic vacuum therapy (EVAC)

internal drainage pigtail stents

gastrointestinal fistulas