UNASSIGNED: Over-the-scope clips (OTSCs) are used for treating gastrointestinal perforations, postoperative anastomotic leakages, and mucosal defect closure after endoscopic resections. However, OTSCs are expensive and associated with fatal complications; therefore, proper OTSC usage is necessary. Criteria of OTSC use for mucosal defect closure after duodenal endoscopic submucosal dissection (ESD) are scarce. We examined closure outcomes with OTSCs and conventional clips in patients undergoing duodenal ESD, analyzed the resected specimen area, estimated the preoperative size of tumors treated with each method, and attempted to clarify the criteria for the use of OTSCs vs conventional clips.
UNASSIGNED: Endoscopic resection was performed for 133 superficial duodenal epithelial tumors from April 2017 to February 2022. Complete closure of mucosal defects after duodenal ESD was attempted for 82 superficial non-ampullary duodenal epithelial tumors, divided into OTSC and control (conventional clips used) groups. Closure outcomes were analyzed.
UNASSIGNED: The overall rate of complete mucosal defect closure in both groups was 98.8%. Significant between-group differences existed in the median estimated tumor size and median resected specimen area.
UNASSIGNED: Conventional clips work well for mucosal defects ≤18 mm after duodenal ESD, but for those >18 mm, a combination of OTSCs may be considered.

Boerhaave syndrome (BS) is a rare but potentially fatal condition. Although surgery is considered the standard treatment, endoscopic therapy has acquired an important role as a minimally invasive management approach. The authors describe 2 cases of middle-aged male patients, presenting with spontaneous esophageal perforation after severe straining and vomiting. In the first case, the patient presented with a bone impaction in the upper esophagus successfully removed by rigid esophagoscopy. After the procedure, a chest X-ray/cervicothoracic computerized tomography scan (CT) showed a left hydropneumothorax and pneumomediastinum with oral contrast leak at the lower esophagus. In the second case, the patient presented to the Emergency Department with severe chest pain after an episode of vomiting. The CT showed a massive pneumomediastinum, subcutaneous emphysema, and an oral contrast leak compatible with BS. The patient was initially submitted to surgical suture, but contrast extravasation persisted after 12 days. After multidisciplinary team discussion of both patients, an upper gastrointestinal endoscopy was performed, which revealed pericentimetric wall defects at the distal esophagus. These were successfully closed using an over-the-scope clip (OTSC). After at least a 9-month follow-up, patients have remained clinically well with no relapse. The authors highlight the severity of these clinical cases and the endoscopic option that proved to be decisive in addressing BS. The favorable outcomes suggest a role for the OTSC approach in closing spontaneous esophageal perforation both as first-line and as rescue therapy after a surgical failure.
A síndrome de Boerhaave (SB) é uma entidade rara, mas potencialmente fatal. Embora a cirurgia seja o tratamento padrão, o tratamento endoscópico tem adquirido um papel importante como opção minimamente invasiva. Os autores descrevem dois casos de doentes do sexo masculino de meia-idade, que apresentaram perfuração esofágica espontânea após esforço emético intenso e vómitos. No primeiro caso, o doente apresentou impactação de um osso no esófago superior, que foi removido com sucesso por esofagoscopia rígida. Após o procedimento, o doente realizou radiografia de tórax e tomografia computorizada (TC) cervico-torácica que evidenciou hidropneumotórax esquerdo e pneumomediastino com extravasamento de contraste oral ao nível do esófago inferior. No segundo caso, o doente apresentou-se no Serviço de Urgência com toracalgia intensa após episódio de vómito. A TC mostrou pneumomediastino exuberante, com enfisema subcutâneo e extravasamento de contraste oral compatível com SB. O doente foi inicialmente submetido a rafia cirúrgica, mas o esofagograma ao 12º dia mostrou persistência de extravasamento do contraste. Após discussão em reunião multidisciplinar, ambos os doentes realizaram endoscopia digestiva alta, com visualização de orifícios pericentimétricos no esófago distal, encerrados com sucesso com a aplicação de clip overthe- scope (OTSC). Após seguimento de pelo menos 9 meses, os doentes permaneceram clinicamente bem, sem evidência de recidiva. Os autores destacam a gravidade desses casos clínicos, bem como a opção endoscópica que se mostrou decisiva no tratamento da SB. Os resultados favoráveis sugerem um papel para a abordagem com OTSC no tratamento da perfuração esofágica espontânea, tanto como tratamento de primeira linha, como terapêutica de resgate após falência do tratamento cirúrgico.

BACKGROUND: Given the high incidence of esophageal cancer in China, an increasing number of patients there are undergoing endoscopic mucosal dissection (ESD). Although the 5-year survival rate after ESD can exceed 95%, esophageal stricture, the most common and serious postoperative complication, affects the long-term prognosis of patients and the quality of life. Autologous mucosal grafts have proven to be successful in preventing stricture after ESD for early esophageal cancer.
OBJECTIVE: To examine the viability of acellular dermal matrix (ADM) as an alternative to autologous mucosa for the prevention of stricture after ESD.
METHODS: This is a prospective, single-center, controlled study. Consecutive patients who underwent ESD surgery and were willing to undergo autologous mucosal transplantation were recruited between January 1 and December 31, 2017. Consecutive patients who underwent ESD surgery and were willing to undergo ADM transplantation were recruited between January 1 to December 31, 2019. A final three-year follow-up of patients who received transplants was conducted.
RESULTS: Based on the current incidence of esophageal stricture, the sample size required for both the autologous mucosal graft group and the ADM group was calculated to be 160 cases. Due to various factors, a total of 20 patients with autologous mucosal grafts and 25 with ADM grafts were recruited. Based on the inclusion exclusion and withdrawal criteria, 9 patients ultimately received autologous mucosal grafts and completed the follow-up, while 11 patients received ADM grafts and completed the follow-up. Finally, there were 2 cases of stenosis in the autologous mucosal transplantation group with a stenosis rate of 22.22% and 2 cases of stenosis in the ADM transplantation group with a stenosis rate of 18.18%, with no significant difference noted between the groups (P = 0.94).
CONCLUSIONS: In this prospective, single-center, controlled trial, we compared the effectiveness of autologous mucosa transplantation and ADM for the prevention of esophageal stricture. Due to certain condition limitations, we were unable to recruit sufficient subjects meeting our target requirements. However, we implemented strict inclusion, exclusion, and withdrawal criteria and successfully completed three years of follow-up, resulting in valuable clinical insights. Based on our findings, we hypothesize that ADM may be similarly effective to autologous mucosal transplantation in the prevention of esophageal stricture, offering a comparable and alternative approach. This study provides a new therapeutic idea and direction for the prevention of esophageal stricture.

Postbanding ulcer bleeds (PBUBs) are an uncommon complication of variceal band ligation. They are often treated with proton pump inhibitors in addition to endoscopic interventions such as epinephrine injections, hemostatic clips, electrothermal cautery, or further band ligation. Over-the-scope clips are being increasingly used for the management of acute nonvariceal upper gastrointestinal bleeds, but their use in the management of PBUBs has been reported only once before. We present a 24-year-old man with alcohol-associated decompensated cirrhosis with recurrent PBUB, despite multiple endoscopic interventions, transjugular intrahepatic portosystemic shunt, and liver transplant, treated successfully with an Ovesco clip.

BACKGROUND: The over-the-scope clip (OTSC) is a highly effective clipping device for refractory gastrointestinal disease. However, Japanese data from multicenter studies for anastomotic leakage (AL) involving a secondary fistula after gastrointestinal surgery are lacking. Therefore, this study evaluated the efficacy and safety of OTSC placement in Japanese patients with such conditions.
METHODS: We retrospectively collected data from 28 consecutive patients from five institutions who underwent OTSC-mediated closure for AL between July 2017 and July 2020.
RESULTS: The AL and fistula were located in the esophagus (3.6%, n = 1), stomach (10.7%, n = 3), small intestine (7.1%, n = 2), colon (25.0%, n = 7), and rectum (53.6%, n = 15). The technical success, clinical success, and complication rates were 92.9% (26/28), 71.4% (20/28), and 0% (0/28), respectively. An age of <65 years (85.7%), small intestinal AL (100%) and colonic AL (100%), defect size of <10 mm (82.4%), time to OTSC placement > 7 days (84.2%), and the use of simple suction (78.9%) and anchor forceps (80.0%) were associated with higher clinical success rates.
CONCLUSIONS: OTSC placement is a useful therapeutic option for AL after gastrointestinal surgery.

BACKGROUND: Endoscopic full-thickness resection (EFTR) without laparoscopic assistance (pure EFTR) is an emerging, less invasive treatment for gastrointestinal stromal tumors (GISTs). However, the technique has seldom been performed outside China because of concerns regarding pneumoperitoneum, maintenance of endoscopic view, and endoscopic suturing. This study aimed to evaluate the efficacy and safety of endoscopic resection with one-port placement (EROPP) for gastric GISTs.
METHODS: This retrospective study included 17 patients with gastric GISTs originating from the muscularis propria who underwent EROPP between 2019 and 2022. One camera port was inserted in the umbilicus before initiating the endoscopic procedure to maintain intra-abdominal pressure, which was monitored and adjusted via this port. While allowing for conversion to laparoscopic surgery if needed, EFTR was performed as follows: (1) circumferential incision of the mucosal and submucosal layers around the lesion was performed by typical endoscopic submucosal dissection; (2) an intentional perforation and subsequent seromuscular resection was made using dental floss and an endo-clip for traction; and (3) closure of the gastric full-thickness defect was performed with an over-the-scope clip (OTSC) after peroral retrieval of the specimen. We retrospectively assessed the short-term outcomes and safety.
RESULTS: All procedures were completed successfully without conversion to laparoscopic surgery. The median size of the resected tumors was 23 mm (range, 8-35 mm), the median resection time was 36 min (range, 22-95 min), and closure time was 18 min (range, 10-45 min). The rates of en bloc and complete resection were 100% and 88%, respectively. In 2 cases, another port was added to aspirate the leaking fluid or check the condition of the endoscopic closure. All gastric defects were endoscopically closed, mainly using OTSCs. The recovery course for all patients was uneventful, and no adverse events were reported.
CONCLUSIONS: EROPP is a safe and minimally invasive treatment for gastric GISTs and appears to be suitable for introducing EFTR procedures.

Duodenal endoscopic submucosal dissection (ESD) is associated with high incidences of intraoperative complications and delayed adverse events (AEs). Delayed AEs can be reduced by closing the post-ESD defects. We developed a new method of closure after duodenal ESD, combining endoscopic ligation with O-ring closure (E-LOC) with an over-the-scope clip (OTSC) (Band OTSC; B-OTSC). Here, we conducted a single-center, retrospective, observational study to investigate the efficacy and safety of the B-OTSC method for preventing delayed AEs in patients undergoing duodenal ESD. The study included nine patients with superficial nonpapillary duodenal epithelial tumors who underwent ESD and were closed with B-OTSC from February 2021 to February 2023. There were no delayed AEs (0%), the mean (± standard deviation) closure time was 53 ± 21.6 min, the complete closure rate was 100%, and the mean hospital stay was 7.8 ± 1.8 days. The sustained closure rates at postoperative days 3 and 7 were 88.9% and 88.9%, respectively. The historical analysis indicated a significant difference in cost between B-OTSC and conventional OTSC (p < 0.01). In conclusion, B-OTSC was a safe, secure, and cost-effective method of closure after duodenal ESD, even in patients with post-ESD defects of more than half the circumference.

Delayed bleeding is the most frequent complication after endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) of large colon polyps. Today, prophylactic clipping with through-the-scope clips (TTSCs) is commonly used to reduce the risk of bleeding. However, the over-the-scope clip (OTSC) system might be superior to TTSCs in achieving hemostasis. This study aims to evaluate the efficacy and safety of prophylactic clipping using the OTSC system after ESD or EMR of large colon polyps.
This is a retrospective analysis of a prospective collected database from 2009 until 2021 of three endoscopic centers. Patients with large (≥ 20 mm) colon polyps were enrolled. All polyps were removed by either ESD or EMR. After the resection, OTSCs were prophylactically applied on parts of the mucosal defect with a high risk of delayed bleeding or/and perforation. The main outcome measurement was delayed bleeding.
A total of 75 patients underwent ESD (67%, 50/75) or EMR (33%, 25/75) in the colorectum. The mean resected specimen diameter was 57 mm ± 24.1 (range 22-98 mm). The mean number of OTSCs placed on the mucosal defect was 2 (range 1-5). None of the mucosal defects were completely closed. Intraprocedural bleeding occurred in 5.3% (ESD 2.0% vs. EMR 12.0%; P = 0.105), and intraprocedural perforation occurred in 6.7% (ESD 8% vs. EMR 4%; P = 0.659) of the patients. Hemostasis was achieved in 100% of cases of intraprocedural bleeding, whereas two patients required surgical conversion due to intraprocedural perforation. Among the remaining 73 patients who received prosphylactic clipping, delayed bleeding occurred in 1.4% (ESD 0% vs. EMR 4.2%; P = 0.329), and delayed perforation occurred in 0%.
The prophylactic partial closure of large post-ESD/EMR mucosal defects using OTSCs could serve as an effective strategy to reduce the risk of delayed bleeding and perforation. The prophylactic partial closure of large complex post-ESD/EMR mucosal defects using OTSCs could serve as an effective strategy to reduce the risk of delayed bleeding and perforation.

A 57-year-old man visited our hospital for acute cholangitis due to common bile duct (CBD) stones in March 2021. Biliary stenting was performed without any complications. The cholangitis improved rapidly. He was re-hospitalized to treat the CBD stones in May 2021. Although endoscopic retrograde cholangiopancreatography was performed, endoscopy caused a perforation of the duodenal bulb. We successfully performed endoscopic closure of the duodenal defect using an over-the-scope clip (OTSC®). Considering that mild CBD dilatation of 10 mm can carry an increased risk of stenosis after surgery, we decided to avoid surgery and perform a follow-up endoscopic treatment. He was re-hospitalized in July 2021. The endoscopy revealed OTSC® in the anterior wall of the duodenal bulb and complete healing of the perforation. We carefully advanced the scope to the second portion of the duodenum while avoiding OTSC®, and the ampulla of Vater was identified. We were then able to remove the stones without any complications. OTSC® was effective in closing a duodenal perforation and enabled us to carry out the retreatment safely and successfully.

A tracheoesophageal fistula (TEF) is a pathological connection between the trachea and esophagus, which can either occur congenitally or be acquired. An acquired TEF may occur secondary to malignancy, chemoradiotherapy, infection, or trauma. Hallmark symptoms typically associated with TEF include choking with food intake, productive cough, pneumonia, or failure to thrive. The management of TEF has predominantly involved surgical or endoscopic intervention such as esophageal or airway stenting, suturing, or ablation. More recently, the endoscopic over-the-scope clip (OTSC) has emerged as an effective method of TEF management. The OTSC grasps the mucosa overlaying lesion and seals the defect, thus making it an effective treatment option for the endoscopic closure of various GI defects such as fistulas, bleeding ulcers, and perforations. We report a case of a TEF, acquired secondary to underlying malignancy, and its successful treatment with the use of an OTSC placement. A 79-year-old female with a significant history of diffuse large B-cell lymphoma (DLBCL) currently undergoing chemotherapy was admitted to the hospital for aspiration pneumonia. She presented with persistent productive cough and subsequent limited oral intake ability while initially presenting for DLBCL six months prior with an enlarging right-sided neck mass. Her positron emission tomography-computed tomography (PET-CT) imaging showed a cavitary lesion in the superior mediastinum with increased fluorodeoxyglucose (FDG) lymphatic uptake. She had an esophagogram followed by an esophagogastroduodenoscopy (EGD), due to aspiration concerns, which demonstrated a fistula site with tracheal secretions about 20 cm from the incisors. An OTSC was used to close the esophageal opening and successful closure was confirmed using real-time fluoroscopic imaging by the unimpeded passage of contrast in the stomach without leakage. At follow-up, she was able to tolerate an oral diet without any significant difficulty or symptom recurrence. We present a case of successful endoscopic management of TEF with an OTSC that resulted in immediate fistula closure and improvement in the patient\'s quality of life. This particular case highlights the ability of OTSC to provide more durable and long-term closure than other management techniques due to its mechanism of grasping more tissue for approximation and its association with less morbidity compared to alternative surgical interventions. Although previous reports describing the technical feasibility and utility of OTSC in TEF repair support its use, there is still a paucity of data exploring the long-term efficacy of OTSC in TEF management; therefore, additional prospective studies are necessary.