Strangulated Ileus Caused by Clips Used for Closure of an Appendiceal Endoscopic Submucosal Dissection Perforation: A Case Report.
Conventional clips used for perforation closure in ESD can cause strangulated ileus, necessitating careful post-procedure monitoring.
Where it sits
this study against the rest of the survodutide (bi 456906) corpusSummary and findings
A 69-year-old man developed strangulated ileus following the use of conventional clips for closure of a bowel perforation during endoscopic submucosal dissection. The clips caused a segment of the small intestine to be drawn into the closing device, necessitating emergency laparoscopic surgery. The patient was discharged on hospital day 8 after the loop was released and the damaged serosa and mesentery were sutured.
Abstract
Perforation developing during endoscopic submucosal dissection (ESD) for colorectal lesions can necessitate halting of the procedure and performing emergency surgery. In some cases, conservative treatment of the perforation is possible using endoscopic clips or over-the-scope-clips (OTSCs). In the case presented herein, while perforation closure was successfully achieved with conventional through-the-scope clips (hereafter referred to as "conventional clips"), the patient developed ileus as a complication, necessitating emergency surgery. The patient was a 69-year-old man who developed strangulated ileus caused by conventional clips placed for closure of a bowel perforation developing after ESD for a lesion in the cecum. We placed several conventional clips and OTSCs to close the perforation and confirmed the absence of any leak at a second-look examination. However, 10 days later, the patient visited our emergency department complaining of abdominal pain. Abdominal contrast-enhanced computed tomography revealed that a segment of the small intestine was drawn into the closing device, resulting in the development of strangulated ileus. We performed laparoscopic surgery and identified the conventional clips that had become caught in the small intestinal serosa/mesentery and led to the formation of a closed bowel loop and bowel obstruction. We released the loop without resection of the intestine. The damaged serosa and mesentery were sutured, and the patient was discharged on hospital day 8. Based on our experience, we suggest that the treating surgeon should bear in mind that even conventional clips used for perforation closure have the potential to grasp organs adjacent to the wall and cause obstruction and the development of symptoms after hospital discharge.
Background
Endoscopic submucosal dissection (ESD) is a procedure used to remove colorectal lesions, but it carries a risk of perforation. Perforations can sometimes be managed conservatively with endoscopic clips, avoiding emergency surgery. This study highlights a complication arising from such a conservative approach, emphasizing the need for caution when using clips for perforation closure.
Methods
The study is a case report involving a 69-year-old male patient who underwent ESD for a cecal lesion. Conventional through-the-scope clips and over-the-scope-clips were used to close a perforation. A second-look examination confirmed no leak. Ten days post-procedure, the patient presented with abdominal pain, and imaging identified strangulated ileus caused by the clips.
Results
The primary observation was the development of strangulated ileus due to conventional clips used in perforation closure. Laparoscopic surgery revealed that the clips had caught in the small intestinal serosa and mesentery, forming a closed bowel loop. The loop was released without resection, and the patient was discharged on hospital day 8.
Interpretation
This case report underscores the potential for conventional clips to cause complications such as bowel obstruction, even when initially successful in perforation closure. While the use of clips can avoid immediate surgery, this case suggests that surgeons should monitor for delayed complications. The findings align with known risks of clip use but highlight a specific mechanism of obstruction.
Key findings
- 69-year-old male patient.
- Strangulated ileus developed 10 days post-procedure.
- Conventional clips caused bowel obstruction.
- Laparoscopic surgery was performed without intestinal resection.
- Patient discharged on hospital day 8.
Limitations
- Single case report.
- Findings specific to one patient.
- No long-term follow-up data.
- Potential for observer bias.