Naval Medical Center San Diego San Diego, CA, United States
Faith Kim, MD, Brian Park, MD, Michael M. Skaret, MD, Joshua McCarron, MD, Richard Bower, MD, R. Lawson, MD Naval Medical Center San Diego, San Diego, CA
Introduction: Endoscopic closure of large mucosal defects can be technically difficult depending on a myriad of factors including the location, size, shape and orientation of the defect, characteristics of the involved tissue, endoscopist experience, and availability and limitations of endoscopic tools. We present three cases of challenging mucosal defects that were successfully managed with readily available tools used in an unconventional manner.
Case Description/Methods: Case 1
A 40-year-old man with eosinophilic esophagitis was found to have mediastinal air on computed tomography after presenting with chest pain and hematemesis. Esophagogastroduodenoscopy (EGD) revealed a deep, linear rent with exposed longitudinal muscle fibers in the distal 10cm of the esophagus.
A 69-year-old man with a remote history of squamous cell carcinoma of the base of the tongue treated with chemotherapy and radiation presented with acute chest pain and scant hematemesis. Chest radiograph was negative for acute findings. Subsequent EGD demonstrated two deep linear mucosal rents with visible muscle fibers in the esophagus measuring 13 cm and 5 cm in length.
A 38-year-old man with an entero-atmospheric fistula suffered an iatrogenic perforation during trans-fistula enteroscopy.
Discussion: In each of these cases, closure was initiated by “zippering” the defect closed using through-the-scope (TTS) hemostasis clips. However, in each case, approximation of the edges with a single TTS clip eventually became impossible due to distance between mucosal edges and edematous tissue. Completion of the closure was achieved by placing clips on both sides of the mucosal defect followed by placement of a detachable loop low on the clips to pull opposing clips and mucosal edges together. All patients recovered well following endoscopy and none required surgery. Unconventional use of readily available endoscopic tools should be considered when faced with unexpected technical challenges while closing mucosal defects. In these cases we successfully employed a technique similar to the “tulip bundle” or King technique when conventional closure with TTS clips failed, thereby maximizing endoscopic therapy and avoiding additional invasive procedures.
Figure: The deep mucosal rents encountered in the esophagus shown in boxes A and B were too wide to approximate the edges with a single TTS hemostasis clip. Boxes C and D illustrate our closure technique in which clips placed on opposite sides of the defect are pulled together using a detachable loop placed low on the clips. Corresponding pairs of clips were drawn together with individual detachable loops to close the linear defects in a zipper-like fashion.
Disclosures: Faith Kim indicated no relevant financial relationships. Brian Park indicated no relevant financial relationships. Michael Skaret indicated no relevant financial relationships. Joshua McCarron indicated no relevant financial relationships. Richard Bower indicated no relevant financial relationships. R. Lawson indicated no relevant financial relationships.
Faith Kim, MD, Brian Park, MD, Michael M. Skaret, MD, Joshua McCarron, MD, Richard Bower, MD, R. Lawson, MD. P0440 - Detachable Loop-Aided Closure of Large Mucosal Defects: A Handy Addition to an Endoscopist’s Toolbox, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.