895845

review-article20192019
CMG0010.1177/2631774519895845Therapeutic Advances in Gastrointestinal EndoscopyJ Al-Asiry, R Lord

Therapeutic Advances in Gastrointestinal Endoscopy Review

Management of spontaneous and iatrogenic

Ther Adv Gastrointest
Endosc

perforations, leaks and fistulae of the upper

2019, Vol. 12: 1–12

DOI: 10.1177/
https://doi.org/10.1177/2631774519895845
2631774519895845
https://doi.org/10.1177/2631774519895845

gastrointestinal tract © The Author(s), 2019.

Article reuse guidelines:
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Jamal Al-Asiry , Richard Lord and Noor Mohammed

Abstract: Upper gastrointestinal perforations, leaks and fistulae are relatively common
occurrences with a growing number of these complications occuring as a result of therapeutic
advancement and adoption of newer and bolder endoscopic therapies. Historically, these
were predominantly managed surgically; however, owing to high morbidity and mortality
associated with surgical repair, endoscopic options are preferable. Over the past decade,
vast expansion in the endoscopic armamentarium for the management of perforations, leaks
and fistulae has led to endoscopic management now being the first-line treatment. Here,
we will review the endoscopic modalities including through-the-scope clips, over-the-scope
clips, stents, vacuum therapy, endoscopic sutures and sealants. In addition, we will discuss
nonendoscopic approach to management including early recognition of perforations, ways to
reduce septic complications and format algorithms to guide therapy for different scenarios.
However, it is important to stress that there is a lack of high-quality randomised studies to
clearly guide management of such complications, resulting in a wide variation of approaches
in management by specialists. Each case requires some degree of individualisation due to the
potential array of problems encountered and patient-specific co-morbidities. In the future,
more robust studies are clearly required to better guide specialist management.

Keywords: acute perforation, endoscopic management, endoscopy vacuum therapy, leaks and
fistulae, over-the-scope clips, stents

Received: 18 May 2019; revised manuscript accepted: 27 November 2019.

Introduction overall incidence of perforation from diagnostic

Historically, upper gastrointestinal (UGI) perfo- UGI endoscopic procedures is low.2 However,
rations were predominantly managed surgically. there is a rising demand on endoscopic services
However, morbidity and mortality associated due to surveillance and screening programmes, as
Correspondence to:
with surgical repair are high.1 Over the past dec- well as the ever-burgeoning indications for thera- Richard Lord
ade, vast expansion in the endoscopic armamen- peutic endoscopies such as endoscopic mucosal Department of
Gastroenterology, Leeds
tarium for the management of perforations, leaks resection (EMR), endoscopic submucosal Teaching Hospitals NHS
and fistulae has led to endoscopic management dissection (ESD), endoscopic retrograde cholan- Trust, Leeds LS97TF, UK.
[email protected]
now being considered the first-line treatment gio-pancreatography (ERCP) and therapeutic
Jamal Al-Asiry
option. Endoscopic therapy is less invasive, avoids endoscopic ultrasound scan (EUS). Therefore, Department of
general anaesthesia in most cases and potentially while perforations during UGI endoscopy are Gastroenterology, Leeds
Teaching Hospitals NHS
reduces extraluminal contamination if the perfo- rare, there is an increase in the absolute number Trust, Leeds, UK
ration is dealt with acutely. of perforations with evolving indications of thera- Richard Lord
peutic endoscopy. In this review article, we will Noor Mohammed
Department of
Perforations of the UGI tract may be spontane- be discussing perforations related to only luminal Gastroenterology, Leeds
ous (e.g. Boerhaave syndrome, peptic ulcer dis- UGI procedures, leaks and fistulae. Complications Teaching Hospitals NHS
Trust, Leeds, UK
ease, malignancy) or iatrogenic as a result of and management of hepatobiliary procedures are University of Leeds, Leeds,
endoscopic or laparoscopic procedures. The not discussed. UK

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Therapeutic Advances in Gastrointestinal Endoscopy 12

Perforations related to endoscopic oesophageal or gastric resections. EMR appears

procedures safer than ESD in the duodenum which carries
the highest risk of both immediate (1.6% versus
Low-risk procedures 12%) and delayed perforation (0.6% versus
A typical diagnostic gastroscopy and EUS is asso- 4.0%).13 This is likely secondary to the practical
ciated with a perforation risk of approximately difficulties of manoeuvring in the relatively nar-
0.03% and 0.01%, respectively.2,3 Most perfora- row duodenal lumen along with the fact that the
tions in a diagnostic gastroscopy occur in the tho- duodenal mucosa is particularly thin compared to
racic oesophagus, whereas for diagnostic UGI other sites in the GI tract. However, there is a role
EUS, they more commonly occur in the duode- for duodenal ESD in selected patients as the pro-
num.4 Duodenal perforation during routine gas- cedure is associated with a higher en bloc resec-
troscopy is exceedingly rare but when they occur tion rate and lower risk of disease recurrence.
they are often caused by muscular trauma during
multiple biopsies from the same site. More com- Endoscopic dilatations in the UGI tract are
monly, perforations of the duodenum are second- among the most hazardous procedures with a
ary to ERCP, and while the majority can be perforation rate of 2–3%.14 The risks are lower
managed conservatively, a minority of ERCP- in simple benign strictures when compared to
related perforations carry significant morbidity malignant strictures (4–6%), complex stric-
and mortality risk.5 tures, caustic strictures and for patients with
achalasia (0–8%).14,15 The rates of complica-
tions in endoscopic dilations of duodenal stric-
High-risk procedures tures are significantly higher. There are two
The perforation risk from EMR and ESD is types of oesophageal dilators: the bougie (or
dependent on the site in the UGI tract where the push) dilator and balloon dilator. Clinical out-
procedure is performed. In the oesophagus, most comes between these two techniques do not dif-
experience with EMR is for the treatment of fer in terms of safety or efficacy; therefore, the
Barrett’s oesophagus and Barrett’s associated choice of dilator used is often dependent on cli-
neoplasia and the rates of perforation range from nician preference, equipment availability, re-
0% to 3%.6,7 Oesophageal ESD is often the first- usability and cost. Although, with respect to
line therapeutic intervention for patients with bougie dilatation, the non-wire-guided bougie
superficial oesophageal squamous cell carcino- oesophageal dilators (e.g. Maloney dilator) have
mas (SCC) and for patients with Barrett’s neo- largely been superseded by wire-guided tech-
plasia with unfavourable characteristics for EMR niques (e.g. Savary-Gilliard and Puestow) due
such as large tumour size (>15 mm), poor ‘lift’ to a superior safety profile.16
and those with suspected submucosal (sm1) inva-
sion. The risk of perforation from oesophageal
ESD is improving with increasing uptake and Anastomotic leaks and fistulae
clinical expertise but has slightly increased rates Leakage from the UGI tract is a feared and life-
of perforation when compared to EMR (range threatening complication of UGI surgery. Surgical
0–4%).8,9 re-intervention for leaks and fistulae is associated
with significant mortality.17 The incidence of
Gastric EMR is a safe procedure which was the anastomotic leakage following gastro-oesopha-
first alternative treatment for early gastric cancer geal anastomosis occurs in up to 40% of cervical
(EGC). Approximately 0.5% of gastric EMR’s are anastomoses compared to 7% of thoracic anasto-
complicated by perforation compared to around moses but morbidity and mortality are greater in
4% of gastric ESD.10,11 Several risk factors for per- the latter.18,19 Risk factors for anastomotic leakage
foration in gastric ESD have been identified can be categorised into modifiable risk factors
including long procedural time, tumour location such as smoking, alcohol misuse, steroid use,
(upper stomach associated with increased risk due malnutrition and nonmodifiable risk factors such
to a thinner mucosa), tumour size, advanced age as age, diabetes, tumour stage, emergency surgery
(>80 years), damaged tissue (i.e. previously irradi- and renal failure.20 A review of the anastomotic
ated) and the presence of an ulcer.10–12 leak rate for each UGI procedure is beyond the
scope of this article. However, anastomotic leaks
Endoscopic resection of duodenal tumours by which are contained or follow a more indolent
EMR or ESD carries higher risk compared to course may form a fistula.

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 J Al-Asiry, R Lord et al.

Figure 1. (a) Acute perforation identified during ESD. Omentum is seen (orange colour–arrow) through the
muscles fibres (white colour). (b) Through-the-scope clip closure.
ESD, endoscopic submucosal dissection.

Oesophageal fistulas in adults are predominantly gastrointestinal bleeding. However, due to ease of
acquired and present with recurrent aspiration their use, they have become essential part of the
pneumonia. They occur primarily as a conse- endoscopic armamentarium from mucosal defect
quence of malignancy, but other causes include closure after EMR to closure of full-thickness per-
trauma, infection, iatrogenic (i.e. oesophageal forations. Endoscopic clips are mainly used to close
stenting, gastroscopy, tracheal tubes), foreign small perforations, with best success at closing per-
bodies (button batteries) and corrosive fluid forations <1 cm.22 Over the last decade, the choice
ingestion. The most common site of fistulous of TTS clips has expanded, with a range of com-
tracts includes the trachea (trachea-oesophageal), mercial clips which differ in their functional prop-
less commonly the bronchus (broncho-oesopha- erties such as size, rotation, tensile and closure
geal) and scarcely the lung parenchyma strength.23
(oesophago-pulmonary).
As the name suggests, TTS clips are placed
Gastroduodenal fistulas are a relatively rare form directly through the biopsy channel. The majority
of gastrointestinal fistulae. They arise primarily as of the available clips have additional functionality
a result of UGI surgery (85–90%) but can form of opening and closing the prongs multiple times
spontaneously as a consequence of malignancy, and can also be rotated in order to achieve ideal
trauma, inflammatory bowel disease and infection. position (see Figures 1 and 2). Additional tips in
Gastrocutaneous fistula can occur if the tract per- order to achieve maximal placement include
sists following removal of a percutaneous endo- applying gentle suction in order to draw the edges
scopic gastrostomy (PEG) tube. Fistulae between of the defect closer and applying a generous num-
duodenum and biliary system are very rare.21 ber of clips in order to achieve a ‘zipper’ fashion
closure. Their success, however, seems to be lim-
ited by the size of the perforation, due to the lim-
Endoscopic armamentarium for UGI ited wing-span of the prongs.
perforations, leaks and fistulas
In addition, the ‘omental patch’ technique is fea-
Endoscopic clips sible in larger gastric perforations where the
Endoscopic clips are commonly used for iatro- omentum is visible through the defect (see Figure
genic perforations during the acute setting when 2). The omentum is suctioned through the perfo-
little or no extraluminal contamination is present. ration and then clipped to the edges to form a
There are two main types of clips, through-the- seal. Minami and colleagues24 reported in a large
scope (TTS) and over-the-scope clips (OTSC). series of 117 patients with gastric perforation fol-
lowing EMR/ESD a clinical success of closure
TTS clips. TTS clips, widely known as haemostatic, using TTSC of 98.3% with only two patients
were introduced initially for the management of requiring emergency surgery.

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Therapeutic Advances in Gastrointestinal Endoscopy 12

Figure 2. (a) The mucosal defect following ESD is shown. (b) On close examination, a microperforation is seen.
(c) Omentum seen (orange colour) through the muscles fibres (white) is then drawn into the endoscope by
continuous suction before deploying TTS clips to close the perforation. (d) Complete closure of the mucosal
defect in a ‘zipper’ fashion is shown.
ESD, endoscopic submucosal dissection; TTS, through-the-scope.

OTSC. OTSCs have been designed to close GI mucosal lacerations during re-intubation. The
perforations/defects of varying sizes. A metal clip best results for OTSCs seem to be for defects
is mounted on the distal tip of the endoscope <2 cm and a further advantage is their ability to
which is then manoeuvred to the concerned area. close chronic well-established leaks and fistulae.
Approximation of the mucosal edges is a key step
and can be achieved usually with gentle suction Numerous case studies and cohort studies have
before deploying the clip using an external han- been published but tend to include small numbers
dle. In larger defects, suction alone is less effective and no randomised control trials exist. A prospec-
and the mucosal edges can be apposed using tive international study involving acute perfora-
graspers or anchors, via a double-channel endo- tions showed a success rate of 89%.3 Furthermore,
scope, prior to clip deployment. a multicentre retrospective study has shown suc-
cess rates of 90% for perforations, 73.3% for leaks
The Ovesco clip (Ovesco Endoscopy AG) is a and 42.9% for fistula closure.25 Examples of
commonly used OTSCs, which have a similar Ovesco usage are shown in Figure 3.
principle but vastly different in design to that
used in the ‘Padlock’ clip (Diagmed Healthcare). The OTSCs are designed as durable implants,
Generally, OTSCs are considered superior to but occasionally removal of the clips is required
TTS clips because of their ability to grasp more for complications such as local inflammation,
tissue, closing larger defects and providing a more ulceration, obstruction and misplaced clips.
compressive force compared with TTS clips. Removal of the Ovesco clip can be achieved by
However, there are limitations for its use; it application of direct current (DC) to the bridges
requires the endoscope to be removed from the of the clip with specific graspers to fragment it
patient to mount the clip and is cumbersome to into pieces. The pieces are then extracted using a
negotiate difficult bends sometimes causing cap to protect the mucosa from laceration.

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 J Al-Asiry, R Lord et al.

Figure 3. (a) An endoscopic diagnosis of Squamous cell cancer of the oesophagus, which was treated with
endoscopic resection followed by radiotherapy. (b) A chronic trachea-oesophageal fistula is seen several years
after the treatment while investigating chronic cough. (c) A over-the-scope clip (padlock clip) is used to close
the defect successfully.

In summary, endoscopic clips are an effective concomitant percutaneous or surgical drainage

method of closing mucosal defects. There is a will also be required.28 Regular chest X-rays may
lack of large prospective studies evaluating clip be required in order to exclude stent displace-
closure of perforations. Verlaan and colleagues ment and gastroscopy is required at around
performed a systematic review of the literature 4 weeks to assess the defect.29
and found overall successful closure was achieved
in 90.2% [n = 359; 95% confidence interval (CI): FCSEMS tend to be used in most cases. However,
87–93%] of cases by using TTSCC and in 87.8% partially covered stents may be placed at gastro-
(n = 58; 95% CI: 78–95%) by using the OTSCs. oesophageal leaks due to the higher risk of stent
migration with FCSEMS. Tissue ingrowth at the
Stents. Stents are used to bridge defects and to proximal end allows anchoring of the stent; how-
direct luminal contents into the UGI tract. There ever, this can make removal of the stents difficult
are several types of covered stents used in the once the fistula/leak has healed.30 Success of
treatment of perforations, leaks and fistulae. defect closure in most studies seems to be around
These include fully covered self-expandable 80%.30–33 The main complication is stent migra-
metal stents (FCSEMS), partially covered self- tion which can vary according to the type of stent
expandable metal stents (PCSEMS) and self- placed. One study suggested the risk of migration
expandable plastic stents (SEPS). They come in being 31% with plastic stents, 26% with FCSEMS
different lengths and diameters and should be and 12% with PCSEMS.31
long enough to cover 3–5 cm proximal and distal
to the defect. Stent placement is performed over Endoscopy vacuum therapy. Endoscopy vacuum
a guide-wire under fluoroscopy usually with therapy (EVT) therapy is based on the original
endoscopic visualisation. Following successful vacuum-assisted therapy used to close external
deployment, most studies perform a contrast wounds. Initially, EVT therapy was trialled for rec-
swallow at 48–72 h to confirm no residual leak, tal leaks and was found to be extremely success-
allowing commencement of oral nutrition.26 For ful.34 Soon after, this technology was adopted for
successful treatment of GI defects, tissue around managing perforations and leaks within the upper
the defect needs to be viable and success is more GI tract.35–37 The most commonly used device is
likely when defects are less than 3 cm in size and the Eso-Sponge® system (B. Braun Melsungen
limited angulation proximal and distal to the Ltd., Melsungen, Germany). It consists of a porous
defect.27 Stents are more commonly used for polyurethane sponge which is placed endoscopi-
mid- and lower oesophageal defects, as cervical cally into the cavity or sometimes intraluminally
placement is challenging and poorly tolerated by next to the defect, if the cavity is small. The sponge
patients. Where perforations and leaks are not works by promoting new granulation tissue, while
contained, stent placement will interfere in the the vacuum removes secretions, reduces oedema
treatment of the collection, and therefore, and promotes healing (see Figure 4).

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Therapeutic Advances in Gastrointestinal Endoscopy 12

Figure 4. (a) Chronic perforation with a cavity. (b) Placement of eso-sponge within the cavity (NJ feeding tube
in situ). (c) Granulation tissue within the cavity during eso-sponge exchange. (d) Complete healing of cavity
following eso-sponge therapy.

Endoscopy is initially performed to assess the size when compared with additional surgery.38 A
of the cavity, and then, an overtube is slid down major benefit of using EVT is that the source of
the shaft of the gastroscope and the tip of the sepsis is being removed and direct assessment of
overtube is placed under direct vision into the the cavity is observed during each sponge change.
cavity. The endoscope is then withdrawn, and the Concomitant feeding can also be achieved by
sponge is placed down the overtube into the cav- placing a naso-jejunal tube. Although some advo-
ity using a pusher device. The overtube/pusher cate enteral feeding to start once the sponge is in
device is then withdrawn, and the tube is redi- place, we would recommend caution and to use
rected through the nose, followed by connection this guidance on a case-by-case basis.
to the vacuum. Endoscopy is then performed to
confirm correct placement, with the vacuum Some drawbacks of EVT include the number of
being switched on under direct endoscopic vision, procedures a patient has to undertake. On aver-
maintaining a negative pressure between 100 and age, five to seven procedures are required before
125 mmHg. Sponge exchange should take place the cavity is healed. Other challenges include
every 72 h to avoid ingrowth of granulation tissue technical difficulties/training and difficulty in
into the sponge. To remove the sponge, 10 ml of removing the sponge if it has been left for too
saline can be flushed down the tube, and then, long.35,36
the tube is pulled out through the mouth, or if
this fails, then grasping forceps close to the sponge Endoscopic suturing. More recently, significant
end can help.34 advances have been made with endoscopic sutur-
ing technology, with several brands on the market.
Clinical success ranges in studies from 70% to Technically, these devices are more challenging to
100% and mortality has shown to be reduced use. The Overstitch (Apollo Endosurgery Inc) is a

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 J Al-Asiry, R Lord et al.

disposable suturing device that is attached at the early recognition of gastrointestinal perforation
end of a double-channel endoscope and allows and facilitates endoscopic management. Perfo­
placement of full-thickness sutures across the rations noted at the time of endoscopy should
defect. Several case reports have shown its effec- be recorded accurately with the site, size, contam-
tiveness in the closure of oesophageal perfora- ination risk, and attempts at endoscopic closure
tions.39 However, larger series have shown less along with the success and where possible
favourable results in the long-term closure, par- photo-documented.
ticularly fistulae after bariatric surgery. In one
study, 71 patients underwent endoscopic suturing Early clinical features suggestive of UGI per-
(EndoCinch; C.R. Bard, Inc), with initial results foration include abdominal pain, chest pain,
of 95% achieving complete primary closure. How- pneumoperitoneum, surgical emphysema and
ever, fistula reopening was seen in 65%, predomi- shortness of breath. At a later stage, they include
nantly in those with large defects (>20 mm).40 peritonitis, systemic inflammatory response syn-
With limited data and small case series, it is diffi- drome, shock and mental obfuscation which are
cult to determine the exact place of endoscopic associated with worse clinical outcomes.44
suturing devices in the algorithm. Patients with an UGI perforation are admitted to
hospital for close monitoring. Computed tomog-
Tissue sealants. Tissue sealants such as fibrin raphy (CT) is superior to plain abdominal/chest
glue and cyanoacrylate have been used with some X-rays in identifying perforations and allows the
success at closing UGI leaks and fistulas.27 They use of oral contrast to evaluate the size of the leak
can be applied as monotherapy or more com- along with the efficacy of endoscopic closure.
monly as part of combined therapy with clips, However, it should be emphasised that the vol-
stents or mesh.41 As with other techniques, the ume of extraluminal air does not correlate well
fistula epithelium is often abraded or treated with with the size of the perforation.45
argon plasma coagulation (APC) prior to applica-
tion of the glue to promote fistula closure.
General management of perforations
The key to management is by adopting a multi-
General principles in the management of disciplinary collaboration from gastroenterolo-
UGI perforations gists, surgeons and radiologists. The majority of
Most studies examining endoscopic management UGI perforations which occur as a result of
of UGI defects are predominantly case reports or endoscopy can be managed endoscopically;
retrospective/prospective cohorts, resulting in sig- however, this is dependent on location, size and
nificant selection and publication bias. Lack of length of time the defect has been present and
high-quality studies, such as randomised con- the expertise of the endoscopist in managing
trolled trials, has consequently led to challenges such complications. General supportive meas-
in drawing consensus and clear guidelines to ures for patients with an UGI perforation include
adhere to. Below is a pragmatic approach to deal- keeping the patient nil by mouth, analgesia,
ing with perforations. nasogastric or nasoduodenal tubes, broad-spec-
trum intravenous antibiotics and high-dose
intravenous acid suppression and for patients
Recognition who are malnourished or expected to have a pro-
The key to successful management of this compli- longed period nil by mouth (>7 days) parenteral
cation is early recognition. Iatrogenic perforations nutrition. Once a perforation has been identi-
can be identified at the index procedure by visuali- fied, intra-procedurally switching to carbon
sation of an obvious mucosal defect or by more dioxide insufflation is recommended to reduce
subtle signs such as abdominal distension and loss the formation of tension pneumothorax or
of luminal distension.42 During EMR or hybrid- pneumo-mediastinum.46 However, urgent nee-
ESD, the ‘target sign’, which is characterised by a dle decompression is indicated in patients with
white/grey circular disc on the resected specimen, haemodynamic compromise who develop these
identifies the muscularis propria and is a marker of life-threatening conditions.
iatrogenic perforation. Swan and colleagues43
demonstrated that meticulous inspection of the The decision to close the defect endoscopically is
resection specimen for the target sign can result in dependent on the timing of the perforation (acute

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Therapeutic Advances in Gastrointestinal Endoscopy 12

Table 1. Initial general management of an acute upper gastrointestinal perforation.

•• Early recognition

•• Confirm insufflation is with CO2

•• Decompress any extraluminal air under pressure

•• Determine if endoscopic closure possible:

  ○ Size of defect
  ○ Location
  ○ Extraluminal contamination
  ○ Skill set of endoscopist

•• Consider insertion of NJ tube at the time of procedure and commence post-pyloric feeding once
radiological confirmation of closed perforation

•• Nil-by-mouth

•• Intravenous antibiotics and proton pump inhibitor

•• Admission and close observations

•• Inform UGI surgeons of admission

•• Radiological imaging with oral contrast to confirm closure or to assess for complications
NJ, nasojejunal; UGI, upper gastrointestinal.

perforation defined as occurring within 24 h), site Within the stomach and duodenum, the size of
of perforation, contamination of luminal con- the perforation is more likely to direct endoscopic
tents, the expertise/skill of the endoscopist and management. Small perforations <1 cm tend to
the stability of the patient. Generally, surgery is be easily managed with TTS clips. Larger defects
advocated in patients who present late with sep- within the stomach maybe closed by the ‘omental
sis, deteriorating condition, and large defects or patch’ technique or OTSC. Omental patch tech-
with an active leak on CT scan. Patients who nique is described in Figure 2. The advantage of
develop collections should have these drained this technique is the perforation closure can take
percutaneously where possible and radiological place without any significant delay, thereby avoid-
examination is likely required to confirm closure ing peritoneal contamination. It is performed
of defect, either with gastrograffin or CT with with the TTS clips, without having to remove the
oral contrast. A summary of management of per- endoscope from the area of perforations.
forations can be seen in Table 1. However, use of OTSCs for closing perforations
will require the endoscope to be removed from
the area of perforation to mount the clip on the
Acute perforations tip of the endoscope before it is re-introduced.
Treatment of acute perforations is dependent on With skilled technician, the delay could be
several factors as described above. For acute reduced; however, the peritoneal contamination
oesophageal perforations, the site of the defect is could not be underestimated. Hence, our practice
particularly important. Treatment of cervical is to suction any excess fluid from the lumen and
oesophageal perforations can be particularly withdraw the endoscope only when the OTSC is
challenging due to anatomical reasons, resulting ready to be mounted.
in poor views and unstable position to achieve
closure and conservative management may be Figures 5–7 describe flow diagrams for acute per-
successful here.47 Thoracic and abdominal forations of the oesophagus, stomach and duode-
oesophageal perforations are more amenable to num. They provide a pragmatic approach to
the various endoscopic modalities discussed ear- management complimenting the general manage-
lier within the paper. ment described in Table 1.

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 J Al-Asiry, R Lord et al.

Figure 5. Flow diagram for the management of an acute oesophageal perforation.

EVT, endoscopic vacuum therapy; FCSEMS, fully covered self-expandable metal stent; OTSC, over-the-scope clip; PCSEMS,
partially covered self-expandable metal stent; TTS, through-the-scope.

Fistulae in general represent the refractory disor-

der to most endoscopic therapy. They may be
associated with malignancy or radiation therapy
rendering treatment challenging. For oesophago-
respiratory fistulae, stenting is likely to be the best
option, especially as most are related to malig-
nancy, and therefore, unlikely to heal, and associ-
ated with the best palliative option.48 Gastric
fistulae relating to PEG removal are best man-
aged with OTSCs; however, recurrence can
occur.49 A flow diagram for the management is
seen in Figure 8.

Conclusion
UGI perforations, leaks and fistulae are relatively
Figure 6. Flow diagram for the management of an common occurrences with a growing number of
acute gastric perforation. these complications occurring as the adoption of
OTSC, over-the-scope clips; TTS, through-the-scope.
newer and bolder endoscopic therapies continues.
The key to managing these complications include
Chronic perforations, leaks and fistulae early recognition, commencement of endoscopic
Chronic perforations and anastomotic leaks can therapy, reducing septic complications, promoting
generally be managed similarly. Decision on nutritional status and implementing a multidiscipli-
treatment will be dependent on the chronicity, nary approach. At present, there is a lack of high-
viability of the underlying tissue, location and quality randomised studies to clearly guide
the presence of any undrained sepsis. EVT is management of such complications, resulting in a
helpful in the presence of undrained sepsis and wide variation of approaches in the management by
eventual closure; however, if percutaneous specialists. However, each case requires some
drainage is already in situ, then OTSC, stents or degree of individualisation due to the array of poten-
EVT therapy may be equally effective. Larger tial problems encountered and patient-specific co-
defects >2 cm may also be better managed with morbidities. More robust studies are required in the
EVT or stents. future to better guide specialist management.

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Therapeutic Advances in Gastrointestinal Endoscopy 12

Figure 7. Flow diagram for the management of acute duodenal perforations.

OTSC, over-the-scope clips; TTS, through-the-scope.

Figure 8. Flow diagram for the management of chronic perforations, anastomotic leaks and fistulae.
EVT, endoscopic vacuum therapy; FCSEMS, fully covered self-expandable stents; OTSC, over-the-scope clips; PCSEMS,
partially covered self-expandable stents.

Conflict of interest statement ORCID iDs

The authors declared no potential conflicts of Jamal Al-Asiry https://orcid.org/0000-0002-1818-
interest with respect to the research, authorship 5918
and/or publication of this article. Richard Lord https://orcid.org/0000-0002-8356-
7824
Funding
The authors received no financial support for the Supplemental material
research, authorship and/or publication of this Supplemental material for this article is available
article. online.

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 J Al-Asiry, R Lord et al.

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