JIMT

Full-thickness gastrointestinal injuries are extensive and heterogeneous lesions with various causes and clinical manifestations. They can be classified into perforation, leakage, and fistula. Full-thickness injuries of the gastrointestinal tract, such as perforations, leaks, and fistulas, have traditionally been treated surgically. However, with the recent developments in endoscopic technology, endoscopic therapy has emerged as a subject of consideration along with surgical treatment. The selection of treatment method may vary depending on several factors, including the patient’s clinical features, the cause, type, and size of full-thickness gastrointestinal damage, the extent of inflammation or damage to surrounding tissues, endoscopic device and the endoscopist’s experience. Before selecting a treatment method, it is important to stabilize the patient's vital signs. Next, it is necessary to determine the location and size of the damaged area, which can be evaluated using imaging tests and endoscopy. If fluid is collected around a damaged area, percutaneous or internal drainage is needed. Treatment is required to block the damaged areas through endoscopy or surgery.

In most cases, iatrogenic perforations of the upper gastrointestinal tract improve after endoscopic treatment. Because perforation usually occurs when the surrounding tissue is healthy, the perforation site heals relatively easily after endoscopic treatment. The most important factor for the successful endoscopic treatment of perforations is prompt diagnosis and treatment. It is important to maintain the patient in a stable state for effective treatment and the rapid diagnosis of perforation during endoscopic procedures. Recent European guidelines recommend suturing with an endoscope clip for perforations less than 2 cm, and temporary covered stent insertion is recommended for perforations larger than 2 cm, because it can be difficult to suture with clips (Fig .1)¹. The easiest endoscopic treatment method is to use a through-the-scope clip, which is most preferred when perforations of around 10 mm occurred. Limitations is the fact that the ligation power of the clip is weak owing to the nature of the clip, and it is difficult to completely seal the perforation site because the clip closured the mucous membrane rather than the entire layer of the perforation site. A few factors need to be considered when attaching clips. There are some differences depending on the type of clip; however, one should always keep in mind that some clips are retracted backward when deploying them. Therefore, it is necessary to hold the mucous membrane with the blade at the end of the clip and apply slight pressure, while deploying the clip, to consider the clip retracting backward when suturing the perforation site. When suturing the perforated area with a clip, it is generally recommended to Start in one corner and work clip by clip to the other corner and also Place a clip in two opposite peripheries (almond-shaped). Suturing from one or both corners seems to be a way to increase treatment success. Relatively large perforations can be closed using a detachable snare with multiple endoclips^2,3. The next method is to use an over-the-scope clip by placing a cap with an over-the-scope clip at the end of the endoscope, pulling both mucous membranes perforated with twin graspers in the forceps hole, and then detaching the clip in the same way as in the band ligation method. This technique has the advantage of closing relatively large perforations (approximately 3 cm)⁴. In a systematic review, the success rate was 90.2% when using the through-the-scope clip, and the success rate was 87.8% when using the over-the-scope clip, showing similar effects⁵. In a prospective study, the success rate of the over-the-scope clip was reported to be 89% in 36 patients with a relatively large perforation of 3 cm or more, demonstrating its usefulness⁶. Endoscopic clips are useful for acute upper gastrointestinal perforations, and over-the-scope clips are recommended for relatively large perforations. In addition, when it is difficult to use an endoscope clip in an esophageal perforation >2 cm, inserting a fully covered, self-expanding stent is also recommended⁷. However, a disadvantage may be that the stent itself can aggravate the defect due to its radial expansion force. The clinical success rate of stent insertion in large-sized esophageal perforations has been reported to be approximately 70% to 100%; therefore, it is still useful in clinical practice⁸. After esophageal stent, the biggest problem in clinical practice is stent migration⁹. Risk factors for stent migration include fully covered stent, small stent diameter, and location in the esophagogastric Junctional area. To prevent this stent migration, various endoscopic techniques; such as Shim’s technique and endoscopic suturing or clipping method and anti-migration stents; such as BETA esophageal stent, Comvi-flare type stent and Lumen-apposing metal stent are introduced^10-12. The following is an E-VAC treatment that has recently been introduced for the treatment of leaks and fistulas at the anastomosis site after esophageal surgery. This method can also be used to treat esophageal perforations¹³. If the size of the iatrogenic perforation is large or it is difficult to close with an over-the-scope clip or stent procedure, E-VAC may be an alternative treatment option. Various new endoscopic suturing option; such as T-tags (TAS; Ethicon, Raritan, NJ, USA), Pledgeted cinches (G-Prox; USGI Medical, San Clemente, CA, USA), Autosuture (Covidien, Dublin, Ireland) and Overstitch (Apollo Medical, St Louis, MO, USA) are being introduced for the treatment of gastrointestinal perforation and some are used in actual clinical practice. Recently, an overstitch endoscopic suturing system has been developed that integrates a suture needle and thread in the shape of forceps so that it can be attached to the end of an endoscope. It is advantageous for suturing a large perforation area, including the serosal layer. However, a 2-channel endoscope must be used, and there are limitations in its use depending on the location of the perforation¹⁴. A schematic diagram of the treatment summary for perforation that occurs during upper endoscopy is follow (Fig. 2). If a perforation is confirmed during the examination, it is necessary to replace it with CO₂ if possible, perform procedures such as clipping or stenting, and begin close communication with the surgeon. Simultaneously, CT with a contrast medium should be performed to check for leakage and perforation size. If the perforation is large and the leakage persists, or the patient's symptoms do not improve after 48 hours, immediate surgery is required¹⁵. In endoscopic treatment, the location of the perforation site is also a very important factor. It has been reported that the results of endoscopic treatment for perforation of the esophagus, stomach, and large intestine are very high. But the duodenum is not⁶.

Figure 1. European guideline of upper gastrointestinal perforation. Based on the article of Paspatis et al. (Endoscopy 2020;52:792-810)¹. TTSC: through-the-scope clip, OTSC: over-the-scope clip.

Figure 2. An algorithm for the management of upper gastrointestinal perforation. Based on the article of Blero and Devière (Nat Rev Gastroenterol Hepatol 2012;9:162-172)¹⁵. ECG: electrocardiogram.

Leakage that occurs at the anastomosis site after upper gastrointestinal surgery is most common in esophagectomy, followed by total gastrectomy. Postoperative anastomotic leakage may result in prolonged hospitalization, and anastomotic leakage after esophagectomy has a mortality rate of approximately 7%–35%. Therefore, early diagnosis and appropriate treatment are important¹⁶. Treatment of anastomotic leakage is not yet standardized, but surgical, conservative, or endoscopic treatment is being performed. Simple drainage can lead to fatal infections if secretions are not properly discharged, and surgery is performed cautiously because of the risk of recurrence or high surgical complications. Recently, leakage treatment through an endoscope has been relatively effective and safe, so it is considered before surgery. However, because there are cases in which endoscopic treatment does not improve, surgery should be considered when endoscopic procedures are difficult or when the clinical status worsens despite endoscopic treatment. In endoscopic treatment, endoscopic vacuum therapy and covered stents are the most commonly used treatment methods for anastomotic leakage. Other methods include clipping or filling with polyglycolic acid (PGA) sheets or Biological glue injection (fibrin glue, histoacryl). The endoscopic method, which has been widely used, involves the insertion of a fully covered, self-expanding metal stent. Intra thoracic leakage is blocked by inserting a stent into the anastomosis, and the inflammation around the leakage is treated through additional percutaneous drainage. The advantage of stent insertion in leaks is the tight closure of the wall defect and restoration of the passage. However, there may be a disadvantage in that the stent itself can aggravate the defect owing to its radial expansion force, resulting in locally reduced blood flow and healing process is delayed. A recent meta-analysis reported a treatment success rate of 61%. Alternatively, endoscopic vacuum therapy is becoming a standard treatment because it has the effect of helping tissue regeneration and providing effective drainage using negative pressure. Endoscopic vacuum therapy demonstrated a high treatment success rate of 81.8% in a recent meta-analysis, with a major complication rate of 5.6% and a mortality rate of 1.2%, showing better results than stent therapy regarding effectiveness and safety¹⁷. However, it has the disadvantage of requiring repeated endoscopic procedures, typically four times on average. Notably, there is a rare possibility of serious bleeding associated with the procedure and the difficulty in the placement of sponge. Recently, VAC-stent, which combines the advantages of stent and endoscopic vacuum therapy, has been devised and introduced. In recent reports on VAC-stent, high technical success rates and clinical success rates are reported^18-20.

Fistulas are usually more difficult to treat compared to perforations or leaks and a combination of several methods rather than a single treatment method is recommended. Therefore, patients with fistulas should be treated through close consultation among the gastroenterology, surgery, and radiology departments. For example, in the treatment of esophageal perforations, leaks, and fistulas, a size greater than 2 cm is important; however, the cause may be more important. Acute perforation or anastomotic leakage can be blocked relatively well with endoscopic treatment; however, endoscopic treatment of fistulas has been reported very poorly²¹. In the case of a fistula with advanced fibrosis, the success rate of endoscopic treatment is low because of the epithelialized track. Additional treatment methods, such as argon plasma coagulation and brush treatment, are necessary. Unlike malignant fistulas, benign fistulas do not respond well to stent implantation, and the possibility of treatment failure increases because of stent-related complications. There have been cases of successful treatment of esophageal fistulas using an over-the-scope clip or through-the-scope clip, and there have been cases of closure using PGA and fibrin glue. Recently, over-the-scope clip has been used to treat perforations or fistulas. In a study using an over-the-scope clip in 47 patients with fistulas, the initial success rate was high at 89%, but recurrence within a month was reported to be 46%²². The endoscopic treatment of fistulas remains challenging. Recently, endoscopic management of fistula closure using through-the-scope tack and suture system has been introduced and has reported relatively good results^23,24 .The following algorithm of fistula treatment recommends that several treatment modalities be mixed and applied for the treatment (Fig. 3)⁷.

Figure 3. Flowchart of proposed algorithm for upper gastrointestinal chronic fistula. Based on the article of Chan et al. (Dig Endosc 2022;34:43-62)⁷. APC: argon plasma coagulation, EVT: endoscopic vacuum therapy, TTSC: through-the-scope clip, OTSC: over-the-scope clip.

In addition to surgery, endoscopic treatment for perforations, leakages, and fistulas of the upper gastrointestinal tract is considered the initial treatment. Endoscopic treatment is relatively effective for perforation and leakage of the upper gastrointestinal tract, but the results of duodenal area and fistula treatment are still unsatisfactory. For a successful endoscopic procedure, selecting an appropriate treatment method and careful clinical follow-up after treatment are required. There are cases in which endoscopic treatment does not improve; therefore, changing to another method may be helpful when one endoscopic treatment method is not effective. And also if endoscopic treatment is difficult or the patient’s clinical status worsens despite endoscopic treatment, appropriate alternatives, such as surgery, should be considered.

No potential conflict of interest relevant to this article was reported.

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