Endoclip

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A single-use rotatable endoclip in packaging Resolution clip.jpg
A single-use rotatable endoclip in packaging

An endoclip is a metallic mechanical device used in endoscopy in order to close two mucosal surfaces without the need for surgery and suturing. Its function is similar to a suture in gross surgical applications, as it is used to join together two disjointed surfaces, but, can be applied through the channel of an endoscope under direct visualization. Endoclips have found use in treating gastrointestinal bleeding (both in the upper and lower GI tract), in preventing bleeding after therapeutic procedures such as polypectomy, and in closing gastrointestinal perforations. Many forms of endoclips exist of different shapes and sizes, including two and three prong devices, which can be administered using single use and reloadable systems, and may or may not open and close to facilitate placement.

Contents

Structure and function

Gastric ulcer with a red spot seen in gastroscopy of a patient with upper gastrointestinal hemorrhage Gastric ulcer 2.jpg
Gastric ulcer with a red spot seen in gastroscopy of a patient with upper gastrointestinal hemorrhage
Successful closure of the gastric ulcer with an endoclip GU with clip.jpg
Successful closure of the gastric ulcer with an endoclip

The endoclip was first described by Hayashi and Kudoh in 1975, [1] and was termed the "staunch clip". Initial attempts to incorporate the clip into applications in endoscopy (such as clipping bleeding blood vessels) were limited by the applicator system of the clip. [1] However, by 1988, an easy to use applicator delivery system was developed, and a functional reloadable endoclip system was described. [2] This consisted of a stainless steel clip (of size approximately 6 mm long and 1.2 mm wide at the prongs) with a metal deployment device (that could be used to insert the clip into the endoscopic camera, and deployed outside the camera) enclosed in a plastic sheath. [1] These clips were initially reloadable.[ citation needed ]

Endoclips in use today have a variety of additional shapes and sizes than the original. Clips with two and three prongs (TriClip, Cook Medical [3] ) have been described and used for various applications. [4] Rotatable clips have been devised to improve localization of deployment. [5] Also, clips that open and close (as opposed to single-deployment) have also been developed (Resolution Clip, Boston Scientific [6] ), and also facilitate the appropriate location of deployment. [7]

When a treatable lesion is identified on endoscopy (such as a bleeding vessel), an endoclip can be inserted through the channel of the endoscope until the sheathed clip is visible on the endoscopic image, and the handle for deployment handed to the nurse assistant. The clip is unsheathed by retraction at the handle, positioned, and "fired" by the assistant to treat the lesion.[ citation needed ]

Applications of endoclips

Gastrointestinal bleeding

Endoclips have found a primary application in hemostasis (or the stopping of bleeding) during endoscopy of the upper (through gastroscopy) or lower (through colonoscopy) gastrointestinal tract. [1] Many bleeding lesions have been successfully clipped, including bleeding peptic ulcers, [4] Mallory-Weiss tears of the esophagus, [8] Dieulafoy's lesions, [9] stomach tumours, [10] and bleeding after removal of polyps. [11] Bleeding peptic ulcers require endoscopic treatment if they show evidence of high risk stigmata of re-bleeding, such as evidence of active bleeding or oozing on endoscopy or the presence of a visible blood vessel around the ulcer. [12] [13] The alternatives to endoscopic clipping of peptic ulcers are thermal therapy (such as electrocautery to burn the vessel causing the bleeding), or injection of epinephrine to constrict the blood vessel. Comparative studies between endoclips and thermal therapy make the point that endoclips cause less trauma to the mucosa around the ulcer than electrocautery, [14] but no definitive advantage to either approach has reached consensus by gastroenterologists. [15] [16]

Other applications

An ulcer seen after polypectomy (left) with a visible vessel suggesting recent bleeding is successfully closed with two endoclips (right) Postpolypectomy ulcer.jpg
An ulcer seen after polypectomy (left) with a visible vessel suggesting recent bleeding is successfully closed with two endoclips (right)

Endoclips have also found an application in preventing bleeding when performing complicated endoscopic procedures. For example, prophylactic clipping of the base of a polyp has been found to be useful in preventing post-polypectomy bleeding, especially in high-risk patients or patients on anticoagulant medications. [17] In addition, clips can be used to close gastrointestinal perforations that may have been caused by complicated therapeutic endoscopy procedures, such as polypectomy, or by the endoscopic procedure itself. [18] Clips have also been used to secure the placement of endoscopic feeding tubes, [19] and to orient the bile duct to assist with endoscopic retrograde cholangiopancreatography, a procedure used to image to bile duct. [20]

Safety

Endoclips have been seen to dislodge between 1 and 3 weeks from deployment, [21] although lengthy clip retention intervals of as high as 26 months have been reported. [1] [9] Endoclips are believed to be safe and no major complications (such as perforation or impaction) have been reported with them, although concern has been raised about blocking the outflow of the bile duct if clips are deployed in the duodenum. [1]

Related Research Articles

Peptic ulcer disease (PUD) is a break in the inner lining of the stomach, the first part of the small intestine, or sometimes the lower esophagus. An ulcer in the stomach is called a gastric ulcer, while one in the first part of the intestines is a duodenal ulcer. The most common symptoms of a duodenal ulcer are waking at night with upper abdominal pain, and upper abdominal pain that improves with eating. With a gastric ulcer, the pain may worsen with eating. The pain is often described as a burning or dull ache. Other symptoms include belching, vomiting, weight loss, or poor appetite. About a third of older people have no symptoms. Complications may include bleeding, perforation, and blockage of the stomach. Bleeding occurs in as many as 15% of cases.

<span class="mw-page-title-main">Upper gastrointestinal bleeding</span> Medical condition

Upper gastrointestinal bleeding is gastrointestinal bleeding in the upper gastrointestinal tract, commonly defined as bleeding arising from the esophagus, stomach, or duodenum. Blood may be observed in vomit or in altered form as black stool. Depending on the amount of the blood loss, symptoms may include shock.

<span class="mw-page-title-main">Angiodysplasia</span> Medical condition

In medicine (gastroenterology), angiodysplasia is a small vascular malformation of the gut. It is a common cause of otherwise unexplained gastrointestinal bleeding and anemia. Lesions are often multiple, and frequently involve the cecum or ascending colon, although they can occur at other places. Treatment may be with colonoscopic interventions, angiography and embolization, medication, or occasionally surgery.

<span class="mw-page-title-main">Esophagogastroduodenoscopy</span> Diagnostic endoscopic procedure

Esophagogastroduodenoscopy (EGD) or oesophagogastroduodenoscopy (OGD), also called by various other names, is a diagnostic endoscopic procedure that visualizes the upper part of the gastrointestinal tract down to the duodenum. It is considered a minimally invasive procedure since it does not require an incision into one of the major body cavities and does not require any significant recovery after the procedure. However, a sore throat is common.

<span class="mw-page-title-main">Dieulafoy's lesion</span> Medical condition

Dieulafoy's lesion is a medical condition characterized by a large tortuous artery most commonly in the stomach wall (submucosal) that erodes and bleeds. It can present in any part of the gastrointestinal tract. It can cause gastric hemorrhage but is relatively uncommon. It is thought to cause less than 5% of all gastrointestinal bleeds in adults. It was named after French surgeon Paul Georges Dieulafoy, who described this condition in his paper "Exulceratio simplex: Leçons 1-3" in 1898. It is also called "caliber-persistent artery" or "aneurysm" of gastric vessels. However, unlike most other aneurysms, these are thought to be developmental malformations rather than degenerative changes.

Enteroscopy is the procedure of using an endoscope for the direct visualization of the small bowel. Etymologically, the word could potentially refer to any bowel endoscopy, but idiomatically it is conventionally restricted to small bowel endoscopy, in distinction from colonoscopy, which is large bowel endoscopy. Various types of enteroscopy exist, as follows:

<span class="mw-page-title-main">Endoscopic ultrasound</span> Medical imaging procedure

Endoscopic ultrasound (EUS) or echo-endoscopy is a medical procedure in which endoscopy is combined with ultrasound to obtain images of the internal organs in the chest, abdomen and colon. It can be used to visualize the walls of these organs, or to look at adjacent structures. Combined with Doppler imaging, nearby blood vessels can also be evaluated.

Stretta is a minimally invasive endoscopic procedure for the treatment of gastroesophageal reflux disease (GERD) that delivers radiofrequency energy in the form of electromagnetic waves through electrodes at the end of a catheter to the lower esophageal sphincter (LES) and the gastric cardia – the region of the stomach just below the LES. The energy heats the tissue, ultimately causing it to swell and stiffen; the way this works was not understood as of 2015, but it was thought that perhaps the heat causes local inflammation, collagen deposition and muscular thickening of the LES and that it may disrupt the nerves there.

<span class="mw-page-title-main">Hemosuccus pancreaticus</span> Medical condition

Hemosuccus pancreaticus is a rare cause of hemorrhage in the gastrointestinal tract. It is caused by a bleeding source in the pancreas, pancreatic duct, or structures adjacent to the pancreas, such as the splenic artery, that bleed into the pancreatic duct, which is connected with the bowel at the duodenum, the first part of the small intestine. Patients with hemosuccus may develop symptoms of gastrointestinal hemorrhage, such as blood in the stools, maroon stools, or melena, which is a dark, tarry stool caused by digestion of red blood cells. They may also develop abdominal pain. It is associated with pancreatitis, pancreatic cancer and aneurysms of the splenic artery. Hemosuccus may be identified with endoscopy (esophagogastroduodenoscopy), where fresh blood may be seen from the pancreatic duct. Alternatively, angiography may be used to inject the celiac axis to determine the blood vessel that is bleeding. This may also be used to treat hemosuccus, as embolization of the end vessel may terminate the hemorrhage. However, a distal pancreatectomy—surgery to remove of the tail of the pancreas—may be required to stop the hemorrhage.

<span class="mw-page-title-main">Colonic polypectomy</span> Removal of colorectal polyps to prevent them turning cancerous

Colonic polypectomy is the removal of colorectal polyps in order to prevent them from turning cancerous.

<span class="mw-page-title-main">Self-expandable metallic stent</span>

A self-expandable metallic stent is a metallic tube, or stent that holds open a structure in the gastrointestinal tract to allow the passage of food, chyme, stool, or other secretions related to digestion. Surgeons insert SEMS by endoscopy, inserting a fibre optic camera—either through the mouth or colon—to reach an area of narrowing. As such, it is termed an endoprosthesis. SEMS can also be inserted using fluoroscopy where the surgeon uses an X-ray image to guide insertion, or as an adjunct to endoscopy.

<span class="mw-page-title-main">Portal hypertensive gastropathy</span> Changes in the mucosa of the stomach in patients with portal hypertension

Portal hypertensive gastropathy refers to changes in the mucosa of the stomach in patients with portal hypertension; by far the most common cause of this is cirrhosis of the liver. These changes in the mucosa include friability of the mucosa and the presence of ectatic blood vessels at the surface. Patients with portal hypertensive gastropathy may experience bleeding from the stomach, which may uncommonly manifest itself in vomiting blood or melena; however, portal hypertension may cause several other more common sources of upper gastrointestinal bleeding, such as esophageal varices and gastric varices. On endoscopic evaluation of the stomach, this condition shows a characteristic mosaic or "snake-skin" appearance to the mucosa of the stomach.

Forrest classification is a classification of upper gastrointestinal hemorrhage used for purposes of comparison and in selecting patients for endoscopic treatment.

Therapeutic endoscopy is the medical term for an endoscopic procedure during which treatment is carried out via the endoscope. This contrasts with diagnostic endoscopy, where the aim of the procedure is purely to visualize a part of the gastrointestinal, respiratory or urinary tract in order to aid diagnosis. In practice, a procedure which starts as a diagnostic endoscopy may become a therapeutic endoscopy depending on the findings, such as in cases of upper gastrointestinal bleeding, or the finding of polyps during colonoscopy.

The non-lifting sign is a finding on endoscopic examination that provides information on the suitability of large flat or sessile colorectal polyps for polypectomy by endoscopic mucosal resection (EMR). When fluid is injected under a polyp in preparation for endoscopic mucosal resection, some polyps do not "lift", indicating that the polyp is not separating from the submucosa. This makes polypectomy more technically difficult, and increases the risk of intestinal perforation if polypectomy is then attempted. It is also thought to be indicative of an early colorectal cancer that has invaded the submucosa significantly, which would make surgical removal of the tumour preferable to allow complete removal of the cancer. Consequently, the non-lifting sign is generally considered to be a contraindication to performing endoscopic mucosal resection.

<span class="mw-page-title-main">Herpes esophagitis</span> Medical condition

Herpes esophagitis is a viral infection of the esophagus caused by Herpes simplex virus (HSV).

Endoscopic mucosal resection is a technique used to remove cancerous or other abnormal lesions found in the digestive tract. It is one method of performing a mucosectomy.

Endoscopic submucosal dissection (ESD) is an advanced surgical procedure using endoscopy to remove gastrointestinal tumors that have not entered the muscle layer. ESD may be done in the esophagus, stomach or colon. Application of endoscopic resection (ER) to gastrointestinal (GI) neoplasms is limited to lesions with no risk of nodal metastasis. Either polypectomy or endoscopic mucosal resection (EMR) is beneficial for patients because of its low level of invasiveness. However, to ensure the curative potential of these treatment modalities, accurate histopathologic assessment of the resected specimens is essential because the depth of invasion and lymphovascular infiltration of the tumor is associated with considerable risk for lymph node metastasis. For accurate assessment of the appropriateness of the therapy, en bloc resection is more desirable than piecemeal resection. For a reliable en bloc resection of GI neoplasms, a new method of ER called endoscopic submucosal dissection (ESD) has been developed.

Hemostatic Powder Spray TC-325 is an inert, highly absorptive mineral agent which is used for the treatment of gastrointestinal bleeding. Applied during endoscopy to bleeding lesions, TC-325 is derived from bentonite, and is used to achieve hemostasis by absorbing water and creating a barrier that leads to mechanical tamponade (pressure) and concentration of clotting factors, resulting in enhanced coagulation. TC-325 was approved for gastrointestinal bleeding from causes other than gastric or esophageal varices. TC-325 results in immediate control of bleeding in 91-93% of cases. Technical success has gradually increased between 2011 and 2019, which may be due to device improvements or physician familiarity with the application of TC-325.

<span class="mw-page-title-main">Kenneth Binmoeller</span> German gastroenterologist

Kenneth Frank Binmoeller is a medical doctor and author of multiple scientific contributions and over 300 publications, as well as the inventor of the lumen-apposing metal stent (LAMS) and AXIOS System. These are medical devices used to relieve blockages while creating a direct connection between two bodily structures. He practices in the field of Gastroenterology with a specialty of Advanced Endoscopic Intervention. Binmoeller has been published for his innovations in medical devices and training in the field of Endoscopy.

References

  1. 1 2 3 4 5 6 Devereaux CE, Binmoeller KF (1999). "Endoclip: closing the surgical gap". Gastrointest. Endosc. 50 (3): 440–2. doi:10.1053/ge.1999.v50.99616. PMID   10462677.
  2. ↑ Binmoeller KF, Thonke F, Soehendra N (1993). "Endoscopic hemoclip treatment for gastrointestinal bleeding". Endoscopy . 25 (2): 167–70. doi:10.1055/s-2007-1010277. PMID   8491134.
  3. ↑ "TriClip Endoscopic Clipping Device" . Retrieved 2007-05-15.
  4. 1 2 Lin HJ, Lo WC, Cheng YC, Perng CL (2007). "Endoscopic hemoclip versus triclip placement in patients with high-risk peptic ulcer bleeding". Am. J. Gastroenterol. 102 (3): 539–43. PMID   17100962.
  5. ↑ Yoshikane H, Hidano H, Sakakibara A, Niwa Y, Goto H (2000). "Feasibility study on endoscopic suture with the combination of a distal attachment and a rotatable clip for complications of endoscopic resection in the large intestine". Endoscopy . 32 (6): 477–80. doi:10.1055/s-2000-648. PMID   10863916.
  6. ↑ "Resolution Clip". Archived from the original on 2006-11-13. Retrieved 2007-05-15.
  7. ↑ Jensen DM, Machicado GA, Hirabayashi K (2006). "Randomized controlled study of 3 different types of hemoclips for hemostasis of bleeding canine acute gastric ulcers". Gastrointest. Endosc. 64 (5): 768–73. doi:10.1016/j.gie.2006.06.031. PMID   17055872.
  8. ↑ Yamaguchi Y, Yamato T, Katsumi N, Morozumi K, Abe T, Ishida H, Takahashi S (2001). "Endoscopic hemoclipping for upper GI bleeding due to Mallory-Weiss syndrome". Gastrointest. Endosc. 53 (4): 427–30. doi:10.1067/mge.2001.111774. PMID   11275881.
  9. 1 2 Teo EK, Fock KM (1998). "Dieulafoy's disease treated by endoscopic haemostatic clipping". J. Gastroenterol. Hepatol. 13 (3): 320–1. doi: 10.1111/j.1440-1746.1998.01547.x . PMID   9570248.
  10. ↑ Cheng AW, Chiu PW, Chan PC, Lam SH (2004). "Endoscopic hemostasis for bleeding gastric stromal tumors by application of hemoclip". Journal of Laparoendoscopic & Advanced Surgical Techniques. Part A. 14 (3): 169–71. doi:10.1089/1092642041255522. PMID   15245670.
  11. ↑ Letard JC, Kaffy F, Rousseau D, Nivet JM (2001). "[Post-polypectomy colonic arterial hemorrhage can be treated by hemoclipping]". Gastroenterol. Clin. Biol. (in French). 25 (3): 323–4. PMID   11395682.
  12. ↑ Sung JJ, Chan FK, Lau JY, Yung MY, Leung WK, Wu JC, Ng EK, Chung SC (2003). "The effect of endoscopic therapy in patients receiving omeprazole for bleeding ulcers with nonbleeding visible vessels or adherent clots: a randomized comparison". Ann. Intern. Med. 139 (4): 237–43. doi:10.7326/0003-4819-139-4-200308190-00005. PMID   12965978. S2CID   24699266.
  13. ↑ Lau JY, Sung JJ, Lee KK, Yung MY, Wong SK, Wu JC, Chan FK, Ng EK, You JH, Lee CW, Chan AC, Chung SC (2000). "Effect of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers". N. Engl. J. Med. 343 (5): 310–6. doi: 10.1056/NEJM200008033430501 . PMID   10922420.
  14. ↑ Cipolletta L, Bianco MA, Marmo R, Rotondano G, Piscopo R, Vingiani AM, Meucci C (2001). "Endoclips versus heater probe in preventing early recurrent bleeding from peptic ulcer: a prospective and randomized trial". Gastrointest. Endosc. 53 (2): 147–51. doi:10.1067/mge.2001.111386. PMID   11174282.
  15. ↑ Lin HJ, Hsieh YH, Tseng GY, Perng CL, Chang FY, Lee SD (2002). "A prospective, randomized trial of endoscopic hemoclip versus heater probe thermocoagulation for peptic ulcer bleeding". Am. J. Gastroenterol. 97 (9): 2250–4. PMID   12358241.
  16. ↑ Kovacs TO, Jensen DM (2007). "Endoscopic treatment of ulcer bleeding". Current Treatment Options in Gastroenterology. 10 (2): 143–8. doi:10.1007/s11938-007-0066-3. PMID   17391629. S2CID   23784398.
  17. ↑ Friedland S, Soetikno R (2006). "Colonoscopy with polypectomy in anticoagulated patients". Gastrointest. Endosc. 64 (1): 98–100. doi:10.1016/j.gie.2006.02.030. PMID   16813811.
  18. ↑ Shimizu Y, Kato M, Yamamoto J, Nakagawa S, Komatsu Y, Tsukagoshi H, Fujita M, Hosokawa M, Asaka M (2004). "Endoscopic clip application for closure of esophageal perforations caused by EMR". Gastrointest. Endosc. 60 (4): 636–9. doi:10.1016/S0016-5107(04)01960-1. PMID   15472698.
  19. ↑ Frizzell E, Darwin P (2006). "Endoscopic placement of jejunal feeding tubes by using the Resolution clip: report of 2 cases". Gastrointest. Endosc. 64 (3): 454–6. doi:10.1016/j.gie.2006.02.051. PMID   16923504.
  20. ↑ Scotiniotis I, Ginsberg GG (1999). "Endoscopic clip-assisted biliary cannulation: externalization and fixation of the major papilla from within a duodenal diverticulum using the endoscopic clip fixing device". Gastrointest. Endosc. 50 (3): 431–6. doi: 10.1053/ge.1999.v50.97369 . PMID   10462673.
  21. ↑ Binmoeller KF, Grimm H, Soehendra N (1993). "Endoscopic closure of a perforation using metallic clips after snare excision of a gastric leiomyoma". Gastrointest. Endosc. 39 (2): 172–4. doi:10.1016/S0016-5107(93)70060-7. PMID   8495838.
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