THE GREAT MISTAKE: A COMPLETELY COLONICAL CLOSURE WITH AN OTSC CLIP PLACED FOR A COLO-RECTAL ANASTOMOTIC FISTULA

Aims:

Colorectal postsurgical leaks and fistulas are severe complications that increase morbidity and mortality. The recent develop of the over-the-scope clip (OTSC) has dramatically decreased the number of surgical reinterventions.

Methods:

A 73 years-old man, with a history of anterior rectal resection for a T3N1 adenocarcinoma followed neoadiuvant chemotherapy, was referred to our unit because of a suspicion of a colo-rectal fistula, developed 30 days after the surgical intervention. A lower GI endoscopy showed, at 5 cm from the anal verge, the presence of a colo-rectal anastomosis with a 9 mm diameter fistula. We decided to close the defect with an 11/6 t OTSC clip (Ovesco – Tübingen, Germany). With a gastroscope, suction technique and the aid of the anchor device, we placed an OTSC clip over the fistula but, after the clip release, we observed a completely colonical lumen closure, also justified from the absence of air coming from the bowel.

Results:

Because of the loss of memory of the nitinol under 4 °C, we decided to irrigate the colonical lumen with cold water (< 4 °C) for 10 min, until the white change of the color of the mucosa. With tooth-rat forceps we removed the OTSC clip, without any complication. After the clip removal, in the same session, we placed another 11/6 t OTSC clip, with the aid of the anchor device, sealing the fistula.

Conclusion:

Endoscopic OTSC closure of colorectal postsurgical leaks and fistulas is a safe technique, with a high success rate in both acute and chronic cases but completely bowel closure is a rare adverse event that can be accidentally happen, especially in non-expert hands. The nitinol loss of memory at < 4 °C water allow OTSC deformation, helping us its removal.