DECEMBER - 20228In My OpinionENDOSCOPIC PERFORATIONS AND THEIR CLOSURE: NO LONGER A TEAR-ABLE SITUATIONChristopher Marshall, MD, Clinical Chief of Gastroenterology, UMass Chan Medical SchoolByPerforation during endoscopy is one of the most dreaded complications for any gastroenterologist. The American Society of Gastrointestinal Endoscopy (ASGE) multicenter registries report a perforation rate of 1 in 2500 or in about 11,000 cases. The presence of Zenker's diverticulum, esophageal strictures, malignancies of the upper GI tract, and duodenal diverticula appear to be the greatest risk factors of perforation during an upper endoscopy. Alternatively, per the American Gastroenterology Association (AGA), Endoscopic Mucosal Resection (EMR) or Endoscopic Submucosal Dissection (ESD) for polyp resection appear to be the highest risk factors during colonoscopy. Historically, perforation closure has been in the domain of surgery due to the need for peritoneal washout, and due to the lack of endoscopic tools to close a perforation. However, a number of devices have now entered the market that give endoscopists the ability to close perforations and protect a patient from further surgery. As endoscopy has evolved to become more therapeutic, so has our ability to remedy our mistakes. The endoscopic approach to perforation closure has many variables. Perforation location (i.e., esophagus, stomach, colon, etc.), size of perforation, and concern for peritoneal spillage all come into play. Recent expert opinion from the AGA recommends that upper GI tract perforations <2cm can be closed with though the scope clips, while lesions >2cm require endoscopic suturing. During colonoscopy a large number of perforations occur in the sigmoid colon due to looping. Additionally, perforations in the right side of the colon
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