Introduction
Iatrogenic defects of the gastrointestinal (GI) tract represent a challenging indication even for experienced endoscopists, with the optimal approach being often a dilemma. The increase of interventional endoscopic procedures and complex surgical operations have generated the requirement for clear options in the occurrence of a perforation or a leak. Current guidelines recommend self-expandable metal stents (SEMS), over the scope clips (OTSC) and through the scope clips (TTSC) depending on the site and the size of the defect, albeit based on low quality, indirect comparisons between different cohorts.1,2 This systematic review and meta-analysis aimed to evaluate the available modalities based on comparative quality studies, to elucidate reliably this field.
Aims & Methods
The systematic research was performed in MEDLINE, Cochrane, and Scopus databases until March 2023 for comparative studies evaluating the successful defect closure using SEMS, OTSC, TTSC or endoscopic vacuum therapy (EVT). Any study including at least one comparison was assessed for eligibility. Clinical success was considered as the primary outcome, representing the successful closure of the defect (perforation, leak). Secondary outcomes included overall adverse events were compared among modalities, whereas cumulative rates of the specific complications were also estimated. Meta-analyses were based on random effects model and the results were reported as odds ratios (OR), with 95% Confidence Intervals (95%CI).
Results
Eight studies with an overall number of 744 patients were included in our analysis. In five of them (497 patients) SEMS were compared with alternatives (OTSC and EVT), whereas OTSC and TTSC were assessed in 3 studies (247 patients). SEMS were found to be significantly inferior to alternatives in achieving the primary outcome [OR: 0.38 (95%CI: 0.14-1.01, p=0.05)], however with high heterogeneity (I2=75%). Interestingly, in subgroup analysis, OTSC achieved significantly higher clinical success than SEMS with OR: 2.07 (95%CI: 1.12-3.85, p=0.02) and reduced heterogeneity (I2=19%), whereas the comparison between SEMS and EVT failed to reach statistical significance [OR: 0.42 (95%CI: 0.005-3.19, p=0.4; I2=85%)]. OTSC and TTSC yielded similar rates of successful defect closure [OR: 0.07 (95%CI: 0.03-0.16), p=0.59; I2=0%]. Considering the secondary outcome, SEMS resulted to more adverse events than alternatives [OR: 13.5 (95%CI: 4.57-37.28, p<0.001; I2=63%)], with stent migration been the most common one (81 cases, 26.1%). In the subgroup analysis, both OTSC and ETV provided significantly less complications [OR: 0.07 (95%CI: 0.03-0.16, p<0.001; I2=0%) and OR: 0.09 (95%CI: 0.02-0.44, p=0.003; I2=59%) respectively]. Finally, only one complication was described in the OTSC vs TTSC group.
Conclusion
The success of endoscopic closure of luminal GI defects using SEMS is inferior to alternatives, especially when compared to OTSC, whereas it results to higher rates of adverse events. On the other hand, TTSC and OTSC seemed to be equivalent regarding efficacy and safety.
References
1. Paspatis GA, Arvanitakis M, Dumonceau JM, Barthet M, Saunders B, Turino SY, et al. Diagnosis and management of iatrogenic endoscopic perforations: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement – Update 2020. Endoscopy. 2020 Sep 11;52(09):792–810.
2. Lee JH, Kedia P, Stavropoulos SN, Carr-Locke D. AGA Clinical Practice Update on Endoscopic Management of Perforations in Gastrointestinal Tract: Expert Review. Clinical Gastroenterology and Hepatology. 2021 Nov;19(11):2252-2261.e2.