LAUSR

A 77-year-old woman was admitted to our Emergency Department for an iatrogenic sigmoid colon perforation that occurred during a diagnostic colonoscopy. The patient complained of moderate abdominal pain without signs of peritonitis. Considering the time since colonoscopy (< 2 hours) and the excellent bowel preparation, an attempt was made to treat the perforation endoscopically. Therapeutic colonoscopy was performed under monitored anesthesia care using a singlechannel therapeutic gastroscope (EG3490K; Pentax Medical, Tokyo, Japan) and CO2 insufflation. A 6-cm large fullthickness wall defect at 25 cm from the anal verge, with active oozing bleeding, was detected (▶Fig. 1). Bleeding was controlled with 1:10000 adrenaline injection; thereafter an endoloop-assisted clip closure was performed. We opened a 30-mm endoloop (HX400U-30; Olympus Medical Systems Corp., Tokyo, Japan) around the wall defect; the cable was anchored to the hole margins by launching, one by one, four 13-mm through-the-scope clips (MD-GHR-230-13-135; Zhejiang Chuangxiang Medical Technology Co., Ltd., Hangzhou, China); then the endoloop was hooked, closed, and finally released (▶Fig. 2). The contrastography showed a 6-mm residual wall defect that was treated deploying a 12-mm t-type over-the-scope clip (OTSC) (Ovesco, Tübingen, Germany), with no contrast agent extravasation at the end. A computed tomography (CT) scan after the procedure confirmed the absence of contrast extravasation on luminal contrastography. The patient was managed conservatively with bowel rest, intravenous fluids, and broad-spectrum antibiotic therapy. After 5 days, oral feeding was resumed and the patient was discharged. A CT scan with colonic contrast injection performed after 3 weeks showed a complete resolution (▶Video 1). The endoloop-assisted clip closure technique has been reported as a therapeutic solution for iatrogenic perforations. The timing since the perforation is crucial in order to effectively close the leak [1–5]. In conclusion, in selected cases, the combined endoscopic rescue therapy with endoloop-assisted clip closure and OTSC can be effective in conservative treatment of colonic perforations.