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Management of a Surgical Gastric Perforation With Endoscopic Suturing
Andrew C. Storm*, Allison Schulman, Christopher C. Thompson
Division of Gastroenterology, Brigham & Women's Hospital, Boston, MA
Background: The endoscopic suturing platform has made available to patients a wide variety of minimally invasive techniques and procedures. Iatrogenic gastrointestinal perforation (GIP) may complicate endoscopy or surgery. Endoscopic management with adherence to surgical principle including debridement, antibiotic lavage, percutaneous drainage of peritoneal free air and full thickness suturing with omental patch should be considered for some of these cases.
Aim: To report a surgical gastric perforation complicating laparoscopic splenectomy managed at a tertiary center with endoscopic suture repair.
Case Report: A 58 year old man with Non-Hodgkin’s lymphoma and splenic mass underwent open splenectomy, complicated by 3cm gastric perforation. CT showed extravasation of enteral contrast into the left subphrenic peritoneal space (figure 1A). Initial management included interventional radiology drains and conservative care including antibiotics and hemodynamic support given a tenuous but stable condition. GI was consulted for endoscopic evaluation 14 days after the surgical perforation and management of the acute perforation, which was complicated by a slow GI bleed as evidenced by maroon stools. EGD using carbon dioxide insufflation demonstrated a 3cm defect on the greater curvature of the stomach (figure 1B), with peritoneal drain displaced through the perforation. The drain was replaced into the peritoneum using forceps and lavage of the peritoneum and removal of necrotic tissue with a snare was performed. A piece of omentum was grasped and pulled into the defect. Next, an esophageal overtube was placed and endoscopic suturing device with 2-0 polypropylene was used to place 12 stitches in a linear fashion to close the defect (figure 2A, 2B). The patient required one additional EGD two weeks later to further address the defect, and 6 interrupted sutures were placed. He did not require further surgical management by 2 months post-OP.
Conclusions: As demonstrated in this case, endoscopic suturing for primary closure of subacute perforations is technically feasible and may be applied to a wide variety of GIP situations including surgical perforations. Endoscopic involvement in complicated surgical cases should be considered similarly to the routine use of interventional radiology for drainage of leaks and fluid collections following surgery. This case highlights the importance of multi-specialty collaboration in the management of patients with GI perforations. Studies to evaluate cost, outcome and patient satisfaction with endoscopic versus traditional surgical management for perforations should be performed.
Figure 1: Gastric perforation. A; arrow pointing to contrast extravasation indicating gastric perforation, B; peritoneal drain within gastric lumen.
  Figure 1: Gastric perforation. A; arrow pointing to contrast extravasation indicating gastric perforation, B; peritoneal drain within gastric lumen.
Figure 2: Endoscopic suturing. A; gastric perforation, B; endoscopic suturing device and closure of perforation.
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