Endoscopic management of gastrointestinal perforations, leaks and fistulas

Table 1 Clinical presentation and preferred endoscopic management according to site of perforation[1,7,8,54]

Location of perforation	Clinical presentation	Preferred endoscopic closure techniques	Comments
Esophagus	Subcutaneous emphysema, neck pain, chest pain, emesis	Small perforations (< 2 cm) can be closed with clips (TTSC or OTSC)	The use of endoscopic techniques may be challenging in the proximal esophagus, due to space constraints and patient intolerance - consider conservative treatment in stable patients
	Tachycardia with chills and fever suggest mediastinitis and sepsis development	Perforations < 2 cm size with everted edges may be treated with OTSC clips	Stent fixation with clip application or suturing techniques may be useful to prevent migration of the stent
		Large perforations (> 2 cm) or defects associated with esophageal stenosis may be managed with fully covered and partially covered SEMS or endoscopic suturing techniques	Fibrin glue application and EVAC use has been reported for closure of esophageal perforations but experiences are limited
Stomach	Abdominal pain, abdominal fullness	Endoscopic clipping techniques (TTSC, OTSC) are the mainstay of gastric perforation closure	Most perforations of the stomach are small defects that occur during EMR, ESD procedures and can be successfully closed with TTSC.
	Breathing deterioration and shock symptoms suggest development of tension pneumoperitoneum	Omental patch closure technique, clipping plus endoloop or OTSC may be an option in closing large defects (> 1 cm)	Closing perforations in proximal stomach may be challenging
	Peritonitis and abscess formation result from leakage of gastric contents	Endoscopic suturing is an optional method especially in closing post-ESD defects	Endoscopic band ligation for gastric perforation closure has been reported but experiences are limited
	Pneumomediastinum and pneumothorax are relatively rare complications of perforations in cardiac region	Endoscopic stents may be useful to treat perforations following pyloric or gastroenteric anastomosis dilation
Duodenum and biliary tract	Retroperitoneal nature of the injuries may mask the severity	Peri-ampullary or biliary tract perforations may be treated with biliary stent placement or TTSC	The use of transparent cap may be helpful in difficult locations
	The severity of perforations varies from asymptomatic retroperitoneal air alone (which is not true perforation), to life-threatening perforations with persistent pancreatic and biliary leaks into retroperitoneal or intraperitoneal space	Large perforations most often require immediate surgery. However, when the defect size < 15 mm consider perforation closure with TTSC, OTSC	Closure of medial duodenal wall defects with clips may be challenging due to risk of clipping the ampulla and anatomic location
		Fully covered duodenal SEMS are also the therapeutic option in nonperiampullary perforations	Nasoduodenal drain to divert pancreatic and biliary secretions may be beneficial
	Peritonitis is a late finding associated with poor outcome		Asymptomatic patients with retroperitoneal air alone need no additional treatment
Colon, Rectum	Abdominal pain, abdominal fullness, subcutaneous emphysema	Small perforations (< 2 cm) can be closed with clips (TTSC or OTSC)	The success rate of endoscopic closure is higher when the perforation is recognized and closed during the same procedure, the quality of bowel preparation is good, and there is no leakage of intraluminal contents
	Breathing deterioration and shock symptoms suggest development of tension pneumoperitoneum	Clipping plus endoloop is an option to close large colonic defects	Large vertical perforations should be closed from top to bottom, and horizontal perforations should be clipped from left to right
	Peritonitis and abscess formation are the consequence of intraluminal fecal leakage	Endoscopic band ligation can also be useful to treat colonic perforations

SEMS: Self-expanding metal stent; OTSC: Over-the-scope clip; TTSC: Through-the-scope clip; EVAC: Endoscopic vacuum- assisted closure; EMR: Endoscopic mucosal resection; ESD: Endoscopic submucosal dissection; ERCP: Endoscopic retrograde cholangio-pancreatography.