Endoluminal suturing may overcome the limitations of clip closure of a gaping wide colon perforation (with videos) Gottumukkala S. Raju, MD, Goro Shibukawa, MD, Ijaz Ahmed, MD, Douglas Brining, DVM, Allison Poussard, Shu-Yuan Xiao, MD, Jonathan Coe, Mike Cropper, Dave Martin, Joanne Hull Galveston, Texas, USA Background: It is unclear whether large gaping perforations of the colon can be closed by the endoluminal route. Objective: To evaluate the feasibility and the outcome of closure of large perforations of colon with clips and sutures by using through-the-endoscope novel devices. Design: Prospective animal study. Setting: University hospital. Patients: Ten pigs. Interventions: Closure of a 4-cm full-thickness colon perforation freshly created by an insulated-tip knife with the InScope Multi-Clip Applier (n Z 6) and with the tissue approximation device (n Z 4). Main Outcome Measurements: (a) Technical feasibility of closure, (b) clinical monitoring for 2 weeks, (c) nec- ropsy (day 14), (d) healing by a dye-leak test and histology. Results: Endoluminal closure of a 4-cm–long colon perforation was successful in 9 of 10 animals. The clips failed to close a gaping wide colon perforation in 1 animal. The sutures were successful in the closure of both non- gaping and gaping perforations. Successful closure resulted in a leakproof sealing at 2 weeks and prevented clin- ical peritonitis in all the animals in the clip-closure group and in 3 of 4 animals in the suture-closure group. Necropsy at 2 weeks revealed mild peritonitis in 2 of the 5 animals in the clip closure group and in 2 of the 4 animals in the suture-closure group; none developed fecal peritonitis. Limitations: None. Conclusions: Endoluminal closure of a 4-cm colon perforation with clips was successful in the majority of cases. Sutures were useful in the closure of gaping colon perforations that could not be closed with clips. Colonic perforation is a serious complication of colonos- copy that frequently requires surgery. 1 Closure of the perforation is accomplished either by laparotomy or laparoscopy, depending on the local expertise. 2,3 Early closure of a colon perforation limits the peritoneal con- tamination and potentially stops the cascade of events that lead to sepsis. 4,5 Although endoclips provide an op- portunity to close the perforation immediately, very little is known about the effectiveness of such repair of colon perforations. 6-9 Although experience with endoluminal closure of a small perforation of the colon by using clips and sutures is encouraging, 10,11 we have observed that perforations longer than 2 cm tend to gape wide apart and that the edges tend to evert (edges sloping out toward the perito- neal cavity), thus making them unsuitable for closure with the currently available clips. 12,13 Having the ability to apply 4 clips quickly before the perforation edges start separat- ing or the ability to place full-thickness sutures through the everted edges of a perforation may be a solution to this problem. Technical feasibility and the outcome of en- doluminal closure of a 4-cm colon perforation were evalu- ated by using the InScope Multi-Clip Applier (IMCA) (InScope, Ethicon Endo-Surgery, Inc, Cincinnati, Ohio), which can apply 4 clips quickly, and by using a through- the-endoscope full-thickness tissue approximation device (TAD; InScope, Ethicon Endo-Surgery, Inc, Cincinnati, Ohio) that can apply the sutures through the endoscope channel. 12-15 MATERIALS AND METHODS The animal studies were approved by the University of Texas Medical Branch Institutional Animal Care and Use Copyright ª 2007 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2006.08.048 906 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 6 : 2007 www.giejournal.org