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Video 1Endoscopic closure of a duodenal perforation using a through-the-scope helix tacking suture-based system.

B. Nulsen D. M. Jensen.

Introduction: Endoscopic full-thickness resection (EFTR) without laparoscopic assistance (pure EFTR) is an emerging, less invasive treatment for gastrointestinal stromal tumors (GISTs). However, the technique has seldom been performed outside China because of concerns regarding pneumoperitoneum, maintenance of endoscopic view, and endoscopic suturing. This study aimed to evaluate the efficacy and safety of endoscopic resection with one-port placement (EROPP) for gastric GISTs. Methods: This retrospective study included 17 patients with gastric GISTs originating from the muscularis propria who underwent EROPP between 2019 and 2022. One camera port was inserted in the umbilicus before initiating the endoscopic procedure to maintain intra-abdominal pressure, which was monitored and adjusted via this port. While allowing for conversion to laparoscopic surgery if needed, EFTR was performed as follows: (1) circumferential incision of the mucosal and submucosal layers around the lesion was performed by typical endoscopic submucosal dissection; (2) an intentional perforation and subsequent seromuscular resection was made using dental floss and an endo-clip for traction; and (3) closure of the gastric full-thickness defect was performed with an over-the-scope clip (OTSC) after peroral retrieval of the specimen. We retrospectively assessed the short-term outcomes and safety. Results: All procedures were completed successfully without conversion to laparoscopic surgery. The median size of the resected tumors was 23 mm (range, 8–35 mm), the median resection time was 36 min (range, 22–95 min), and closure time was 18 min (range, 10–45 min). The rates of en bloc and complete resection were 100% and 88%, respectively. In 2 cases, another port was added to aspirate the leaking fluid or check the condition of the endoscopic closure. All gastric defects were endoscopically closed, mainly using OTSCs. The recovery course for all patients was uneventful, and no adverse events were reported. Conclusions: EROPP is a safe and minimally invasive treatment for gastric GISTs and appears to be suitable for introducing EFTR procedures. [ABSTRACT FROM AUTHOR]

Background: Delayed bleeding is the most frequent complication after endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) of large colon polyps. Today, prophylactic clipping with through-the-scope clips (TTSCs) is commonly used to reduce the risk of bleeding. However, the over-the-scope clip (OTSC) system might be superior to TTSCs in achieving hemostasis. This study aims to evaluate the efficacy and safety of prophylactic clipping using the OTSC system after ESD or EMR of large colon polyps. Methods: This is a retrospective analysis of a prospective collected database from 2009 until 2021 of three endoscopic centers. Patients with large (≥ 20 mm) colon polyps were enrolled. All polyps were removed by either ESD or EMR. After the resection, OTSCs were prophylactically applied on parts of the mucosal defect with a high risk of delayed bleeding or/and perforation. The main outcome measurement was delayed bleeding. Results: A total of 75 patients underwent ESD (67%, 50/75) or EMR (33%, 25/75) in the colorectum. The mean resected specimen diameter was 57 mm ± 24.1 (range 22–98 mm). The mean number of OTSCs placed on the mucosal defect was 2 (range 1–5). None of the mucosal defects were completely closed. Intraprocedural bleeding occurred in 5.3% (ESD 2.0% vs. EMR 12.0%; P = 0.105), and intraprocedural perforation occurred in 6.7% (ESD 8% vs. EMR 4%; P = 0.659) of the patients. Hemostasis was achieved in 100% of cases of intraprocedural bleeding, whereas two patients required surgical conversion due to intraprocedural perforation. Among the remaining 73 patients who received prosphylactic clipping, delayed bleeding occurred in 1.4% (ESD 0% vs. EMR 4.2%; P = 0.329), and delayed perforation occurred in 0%. Conclusions: The prophylactic partial closure of large post-ESD/EMR mucosal defects using OTSCs could serve as an effective strategy to reduce the risk of delayed bleeding and perforation. The prophylactic partial closure of large complex post-ESD/EMR mucosal defects using OTSCs could serve as an effective strategy to reduce the risk of delayed bleeding and perforation. [ABSTRACT FROM AUTHOR]

Background: The over-the-scope clip (OTSC) is a highly effective clipping device for refractory gastrointestinal disease. However, Japanese data from multicenter studies for anastomotic leakage (AL) involving a secondary fistula after gastrointestinal surgery are lacking. Therefore, this study evaluated the efficacy and safety of OTSC placement in Japanese patients with such conditions. Methods: We retrospectively collected data from 28 consecutive patients from five institutions who underwent OTSC-mediated closure for AL between July 2017 and July 2020. Results: The AL and fistula were located in the esophagus (3.6%, n = 1), stomach (10.7%, n = 3), small intestine (7.1%, n = 2), colon (25.0%, n = 7), and rectum (53.6%, n = 15). The technical success, clinical success, and complication rates were 92.9% (26/28), 71.4% (20/28), and 0% (0/28), respectively. An age of <65 years (85.7%), small intestinal AL (100%) and colonic AL (100%), defect size of <10 mm (82.4%), time to OTSC placement > 7 days (84.2%), and the use of simple suction (78.9%) and anchor forceps (80.0%) were associated with higher clinical success rates. Conclusion: OTSC placement is a useful therapeutic option for AL after gastrointestinal surgery. [ABSTRACT FROM AUTHOR]

Duodenal endoscopic submucosal dissection (ESD) is associated with high incidences of intraoperative complications and delayed adverse events (AEs). Delayed AEs can be reduced by closing the post-ESD defects. We developed a new method of closure after duodenal ESD, combining endoscopic ligation with O-ring closure (E-LOC) with an over-the-scope clip (OTSC) (Band OTSC; B-OTSC). Here, we conducted a single-center, retrospective, observational study to investigate the efficacy and safety of the B-OTSC method for preventing delayed AEs in patients undergoing duodenal ESD. The study included nine patients with superficial nonpapillary duodenal epithelial tumors who underwent ESD and were closed with B-OTSC from February 2021 to February 2023. There were no delayed AEs (0%), the mean (± standard deviation) closure time was 53 ± 21.6 min, the complete closure rate was 100%, and the mean hospital stay was 7.8 ± 1.8 days. The sustained closure rates at postoperative days 3 and 7 were 88.9% and 88.9%, respectively. The historical analysis indicated a significant difference in cost between B-OTSC and conventional OTSC (p < 0.01). In conclusion, B-OTSC was a safe, secure, and cost-effective method of closure after duodenal ESD, even in patients with post-ESD defects of more than half the circumference. [ABSTRACT FROM AUTHOR]

Background and Aims: Over-the-scope clips (OTSCs) are used for treating gastrointestinal perforations, postoperative anastomotic leakages, and mucosal defect closure after endoscopic resections. However, OTSCs are expensive and associated with fatal complications; therefore, proper OTSC usage is necessary. Criteria of OTSC use for mucosal defect closure after duodenal endoscopic submucosal dissection (ESD) are scarce. We examined closure outcomes with OTSCs and conventional clips in patients undergoing duodenal ESD, analyzed the resected specimen area, estimated the preoperative size of tumors treated with each method, and attempted to clarify the criteria for the use of OTSCs vs conventional clips. Methods: Endoscopic resection was performed for 133 superficial duodenal epithelial tumors from April 2017 to February 2022. Complete closure of mucosal defects after duodenal ESD was attempted for 82 superficial non-ampullary duodenal epithelial tumors, divided into OTSC and control (conventional clips used) groups. Closure outcomes were analyzed. Results: The overall rate of complete mucosal defect closure in both groups was 98.8%. Significant between-group differences existed in the median estimated tumor size and median resected specimen area. Conclusion: Conventional clips work well for mucosal defects ≤18 mm after duodenal ESD, but for those >18 mm, a combination of OTSCs may be considered.

Abstract Background The recently developed endoscopic full-thickness resection technique requires reliable closure. The main closure methods are the purse-string suture (PSS) technique and over-the-scope clip (OTSC) technique; however, basic data on the closure strength of each technique are lacking. This study was performed to compare the closure strengths of these two methods in an ex vivo porcine model. Methods In the traction test, a virtual 5-cm full-thickness closure line was closed by the following six methods three times each: conventional hemoclips, mucosal PSS, seromuscular PSS, mucosal OTSC, seromuscular OTSC, and surgical suture. The primary endpoint was the tension at the starting point of dehiscence, measured in Newtons (N) by an automatic traction machine. In the leak test, a 15-mm gastric full-thickness defect was closed by PSS or OTSC six times each, and the closed stomach was then pressurized in a water container. The primary endpoint was the leak pressure when air bubbles appeared. The secondary endpoints were the procedure time and presence of complete inverted closure. Results The mean tension was 2.16, 3.68, 5.15, 18.30, 19.30, and 62.40 N for conventional hemoclips, mucosal PSS, seromuscular PSS, mucosal OTSC, seromuscular OTSC, and surgical suture, respectively. Complete inverted closure was observed for seromuscular PSS, seromuscular OTSC, and surgical suture. The mean leak pressure was 13.7 and 24.8 mmHg in the PSS and OTSC group, respectively (P

Boerhaave syndrome (BS) is a rare but potentially fatal condition. Although surgery is considered the standard treatment, endoscopic therapy has acquired an important role as a minimally invasive management approach. The authors describe 2 cases of middle-aged male patients, presenting with spontaneous esophageal perforation after severe straining and vomiting. In the first case, the patient presented with a bone impaction in the upper esophagus successfully removed by rigid esophagoscopy. After the procedure, a chest X-ray/cervicothoracic computerized tomography scan (CT) showed a left hydropneumothorax and pneumomediastinum with oral contrast leak at the lower esophagus. In the second case, the patient presented to the Emergency Department with severe chest pain after an episode of vomiting. The CT showed a massive pneumomediastinum, subcutaneous emphysema, and an oral contrast leak compatible with BS. The patient was initially submitted to surgical suture, but contrast extravasation persisted after 12 days. After multidisciplinary team discussion of both patients, an upper gastrointestinal endoscopy was performed, which revealed pericentimetric wall defects at the distal esophagus. These were successfully closed using an over-the-scope clip (OTSC). After at least a 9-month follow-up, patients have remained clinically well with no relapse. The authors highlight the severity of these clinical cases and the endoscopic option that proved to be decisive in addressing BS. The favorable outcomes suggest a role for the OTSC approach in closing spontaneous esophageal perforation both as first-line and as rescue therapy after a surgical failure.

The management of upper gastrointestinal hemorrhage has improved considerably with advances in endoscopic management techniques and peri-interventional care. Although traditional endoscopic treatments remain irreplaceable to date, new endoscopic techniques are emerging and could rapidly change our practices. For instance, in ulcer disease, OTSC (over-the-scope-clip) has a high success rate as a rescue treatment or as first-line treatment for bleeding ulcers that are difficult to treat. Hemostatic powders are safe, easy to use and allow rapid rescue hemostasis especially for diffuse or difficult to treat lesions. The use of endoscopic suture systems is also under development. In case of refractory bleeding, embolization during arteriography or hemostasis surgery should always be considered. In the management of gastrointestinal bleeding secondary to portal hypertension, elastic ligation of esophageal varices or injection of glue into gastric varices remain the first-line treatments. The use of echo-endoscopy to better guide the injection of biological glue in the treatment of gastric varices is a technique under development. A covered self-expanding metal esophageal stent may be considered as an alternative to the tamponade tube (Blackmore) for refractory bleeding. In this paper, we will discuss the main advances in endoscopic hemostasis techniques for upper gastrointestinal bleeding. [ABSTRACT FROM AUTHOR]

Boerhaave syndrome is spontaneous rupture of distal esophagus, caused by sharp increase intra esophageal pressure and negative intrathoracic pressure as with sudden forceful vomiting or retching. Classical Mackler clinical triad consists of vomiting, chest pain and subcutaneous emphysema. Mediastinal infection and sepsis are serious complications and can result in mortality upto 30 %, delay in treatment results in significant increase in mortality and morbidity. Early surgery is the best treatment option, surgery in elderly patients with multiple comorbid illness is challenging. Availability of full thickness closure devices using endoscopy like OTSC clips has a role in treating such group of patients. We present a elderly person who presented to us late and successfully managed endoscopically [ABSTRACT FROM AUTHOR]

Background: The recently developed endoscopic full-thickness resection technique requires reliable closure. The main closure methods are the purse-string suture (PSS) technique and over-the-scope clip (OTSC) technique; however, basic data on the closure strength of each technique are lacking. This study was performed to compare the closure strengths of these two methods in an ex vivo porcine model. Methods: In the traction test, a virtual 5-cm full-thickness closure line was closed by the following six methods three times each: conventional hemoclips, mucosal PSS, seromuscular PSS, mucosal OTSC, seromuscular OTSC, and surgical suture. The primary endpoint was the tension at the starting point of dehiscence, measured in Newtons (N) by an automatic traction machine. In the leak test, a 15-mm gastric full-thickness defect was closed by PSS or OTSC six times each, and the closed stomach was then pressurized in a water container. The primary endpoint was the leak pressure when air bubbles appeared. The secondary endpoints were the procedure time and presence of complete inverted closure. Results: The mean tension was 2.16, 3.68, 5.15, 18.30, 19.30, and 62.40 N for conventional hemoclips, mucosal PSS, seromuscular PSS, mucosal OTSC, seromuscular OTSC, and surgical suture, respectively. Complete inverted closure was observed for seromuscular PSS, seromuscular OTSC, and surgical suture. The mean leak pressure was 13.7 and 24.8 mmHg in the PSS and OTSC group, respectively (P < 0.01). The mean procedure time was 541 and 169 s in the PSS and OTSC group, respectively (P < 0.01). Complete inverted closure was observed in OTSC alone. Conclusion: The OTSC, which allows complete inverted closure, showed greater closure strength than PSS. Considering the size limitation suitable for single OTSC, a therapeutic strategy for closing the larger size is further warranted. [ABSTRACT FROM AUTHOR]

Percutaneous endoscopic gastrostomy (PEG) is a common method for providing long-term enteral nutrition to patients. PEG tube placement and removal are relatively safe; generally, a PEG tube can be removed using gentle traction, and excessive bleeding is rare. The over-the-scope clip system is a new device that can be used for gastrointestinal hemostasis and for closing gastrointestinal fistulae. In the present case, a 68-year-old male patient had to remove the PEG tube because of persistent leakage around the PEG tube. Although it was gently removed using traction, incessant bleeding continued, with a Rockall score of 5 points, even after hemocoagulation was attempted. An over-the-scope clip device was used to achieve hemostasis and fistula closure.

Since the earliest reports, advanced clipping systems have been developed, and it is possible to choose among many models with different structural and technical features. The main drawback of through-the-scope clips is their small size, which allows the compression of limited amounts of tissue needed for large-size vessel treatment. Therefore, the over-the-scope clip system was realized, allowing a larger and stronger mechanical compression of large tissue areas, with excellent results in achieving a definitive hemostasis in difficult cases. Many studies have analyzed the indications and efficacy of two-pronged endoclips and have shown good results for initial and permanent hemostasis. The aim of this review was to provide updated information on indications, positioning techniques, and results of clip application for endoscopic treatment of upper gastrointestinal non-variceal bleeding lesions.

Iatrogenic Stapfer type-1 duodenal perforations during endoscopic retrograde cholangiopancreatography (ERCP) typically necessitate surgical management and carry significant morbidity and mortality risk. Here, we present a case of a large duodenal perforation during ERCP managed endoscopically with an over-the-scope clip (OTSC) and describe the subsequent post-procedural management. An 80-year-old woman presented to the emergency department with acute cholangitis. Abdominal ultrasound scan revealed a dilated biliary tree with echogenic material in the common hepatic and intrahepatic ducts. The patient proceeded to ERCP, where filling defects consistent with stones were found in the proximal main bile duct on cholangiogram. Stone retrieval was complicated by a large iatrogenic perforation of the infero-lateral duodenal wall, distal to the major ampulla (Stapfer type-1). Following unsuccessful attempts to close the defect using through-the-scope clips, a decision was made to attempt closure endoscopically using an OTSC. The duodenoscope was exchanged for a forward-viewing gastroscope mounted with the OTSC. The perforation defect was fully suctioned into the cap and the clip was successfully deployed. Subsequent on-table fluoroscopy with contrast injection did not demonstrate any extra-luminal contrast leak. The patient developed a post-procedure infra-duodenal collection, however, made a complete recovery with bowel rest, negative pressure regulation at the site of the OTSC using a dual-lumen nasogastric/nasojejunal feeding tube and intravenous piperacillin-tazobactam. Thus, OTSCs potentially offer a safe and effective endoscopic treatment modality for the immediate management of ERCP-related Stapfer type-1 duodenal perforations.

Background: The over-the-scope clip (OTSC) is a highly effective clipping device for refractory gastrointestinal disease. However, Japanese data from multicenter studies for anastomotic leakage (AL) involving a secondary fistula after gastrointestinal surgery are lacking. Therefore, this study evaluated the efficacy and safety of OTSC placement in Japanese patients with such conditions. Methods: We retrospectively collected data from 28 consecutive patients from five institutions who underwent OTSC-mediated closure for AL between July 2017 and July 2020. Results: The AL and fistula were located in the esophagus (3.6%, n = 1), stomach (10.7%, n = 3), small intestine (7.1%, n = 2), colon (25.0%, n = 7), and rectum (53.6%, n = 15). The technical success, clinical success, and complication rates were 92.9% (26/28), 71.4% (20/28), and 0% (0/28), respectively. An age of 7 days (84.2%), and the use of simple suction (78.9%) and anchor forceps (80.0%) were associated with higher clinical success rates. Conclusion: OTSC placement is a useful therapeutic option for AL after gastrointestinal surgery.

Atrioesophageal fistula (AEF) is a rare and serious complication of atrial fibrillation (AF) ablation, forming a connection between the atrium and esophagus. A systematic treatment approach for AEF has not been established to date. Herein, we report the case of a young male patient with left AEF after AF catheter ablation, which was successfully treated with the Over-the-Scope Clip (Ovesco Endoscopy AG, Tübingen, Germany) and conservative management. Despite having a double-orifice mitral valve and tricuspid valve, the patient had no symptoms or valve disease. The patient was readmitted three weeks after the procedure owing to fever, hematemesis, consciousness disturbance, hemiplegia, and systemic convulsions. Indigenous bacteria in the oral cavity were detected in blood culture. Magnetic resonance imaging of the brain showed multiple cerebral infarctions. Chest computed tomography showed mediastinal air, suggesting an AEF diagnosis. Subsequently, an endoscopic closure using the Over-the-Scope Clip was performed, leading to a successful recovery and patient discharge on day 87 after admission. This is the first case report of a successful management of AEF after radiofrequency ablation using the Over-the-Scope Clip system. Although surgery is the main treatment for AEFs, we performed nonsurgical management using the clip, demonstrating a potential treatment option for AEF. Surgical intervention is usually superior to endoscopic intervention and conservative management for treatment of atrioesophageal fistula. To the best of our knowledge, this is the first case to be successfully managed by endoscopic clipping and conservative management. [ABSTRACT FROM AUTHOR]

While perforations, postoperative fistulas, and leaks have traditionally led to surgical or interventional radiology consultation for management, the introduction of the over-the-scope clip has allowed increased therapeutic possibilities for endoscopists. While primarily limited to case reports and series, the over-the-scope clip successfully manages gastrointestinal bleeding, perforations, as well as postoperative leaks and fistulas. Retrospective studies have demonstrated a relatively high success rate and a low complication rate. Given the similarity to variceal banding equipment, the learning curve with the over-the-scope clip is rapid. However, given the higher risk of procedures involving the use of the over-the-scope clip, it is essential to obtain the scope in a stable position and grasp sufficient tissue with the cap using a grasping tool and/or suction. From our experience, while closure may be successful in lesions sized up to 3 cm, successful outcomes are obtained for lesions sized

Abstract Gastropleural fistula (GPF) is a rare pathological communication between the stomach and pleura. It may complicate sleeve gastrectomy (SG). An endoscopic application of OTSC can be used to manage GPF.

Since the earliest reports, advanced clipping systems have been developed, and it is possible to choose among many models with different structural and technical features. The main drawback of through-the-scope clips is their small size, which allows the compression of limited amounts of tissue needed for large-size vessel treatment. Therefore, the over-the-scope clip system was realized, allowing a larger and stronger mechanical compression of large tissue areas, with excellent results in achieving a definitive hemostasis in difficult cases. Many studies have analyzed the indications and efficacy of two-pronged endoclips and have shown good results for initial and permanent hemostasis. The aim of this review was to provide updated information on indications, positioning techniques, and results of clip application for endoscopic treatment of upper gastrointestinal non-variceal bleeding lesions. [ABSTRACT FROM AUTHOR]

The Over-The-Scope Clip (OTSC) can effectively treat refractory gastrointestinal diseases. However, most reports have focused on short-term effectiveness. We examined clinical outcomes of the deployed clips and long-term characteristics. Of 47 patients with OTSC treatment, 35 with follow-up periods of ≥3 months were retrospectively examined. The indications were 11 bleedings, 17 perforations, and seven fistulas. The observation period was defined as medium-term (3 to <12 months) or long-term (≥12 months). The primary outcome was the clinical success rate without disease recurrence. The secondary outcomes were the complication rate, survival duration, and clip retention rate. The medium- and long-term clinical success rates were 100% during the observation period (median, 44 months; range, 3–78 months). The complication rate was 2.9% (n = 1). The median survival time was 1,634 days for bleeding, 1,757 days for perforation, and 444 days for fistulas. The overall clip retention rates were 56.4%, 38.1%, 30.9%, and 25.9% after one, six, and 12 months and at the final follow-up, respectively. The average clip retention duration was 244 days in bleeding, 656 days in perforations, and 188 days in fistulas. Regardless of clip detachment, the OTSC can be effective in long-term. [ABSTRACT FROM AUTHOR]

Percutaneous endoscopic gastrostomy (PEG) is one of the most commonly performed endoscopic procedures and a first-line treatment for the establishment of enteral access in those with intolerance or contraindication to oral feedings. A small amount of pneumoperitoneum in the immediate postprocedure period is well reported after PEG tube placement. However, pneumoperitoneum resulting from displaced gastric bumper within 24 hours postprocedure is uncommon and rarely reported in the literature. Timely diagnosis and early endoscopic management can help tackle such an unusual complication.

Abstract Endoscopic ultrasonography (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) for pancreatobiliary diseases require advanced techniques. We usually use an oblique‐viewing endoscope in such procedures. Sometimes, tumor invasion causes gastrointestinal strictures. Crossing a stricture using an oblique‐viewing endoscope is more difficult than using a forward‐viewing scope. Therefore, the frequency of scope perforation is higher than other endoscopic procedures. Although surgical repair for gastrointestinal perforations caused by endoscopes has been performed, patients with pancreatobiliary diseases are often elderly and in poor general condition; therefore, patients are hesitant to undergo surgical treatments. Recently, the usefulness of over‐the‐scope clipping (OTSC) as a minimally invasive rescue method has also been reported. In this study, we report cases of successful endoscopic closure using OTSC for gastrointestinal perforations caused by endoscopes in ERCP and EUS‐related procedures. After those procedures, all cases showed no abnormalities in blood tests or symptoms, and emergency surgery was successfully avoided. Thus, endoscopic closure using OTSC for pancreatobiliary endoscopy‐related gastrointestinal perforations is safe and effective. However, OTSC requires some expertise. A good assessment of defect size and careful insertion of the scope using OTSC attached to the upper esophagus are needed to avoid clip migration or disinsertion and esophageal tears. Therefore, endoscopic closure using OTSC could be the first choice of treatment for pancreatobiliary endoscopy‐related gastrointestinal perforations. We should be familiar with its indication and perform it carefully and rapidly.

An 86-year-old woman presented with a history of endoscopic papillary sphincterotomy for bile duct stones and diverticulitis. The patient was admitted as an emergency case of acute cholangitis due to choledocholithiasis, underwent endoscopic bile duct stenting, and was discharged with a plan for endoscopic lithotripsy. One month later, the patient was readmitted owing to abdominal pain. Abdominal computed tomography at admission showed that the bile duct stent had migrated to the sigmoid colon and the presence of a small amount of extraintestinal gas, suggesting a colonic perforation. Lower gastrointestinal endoscopy showed adhesions and intestinal stenosis in the sigmoid colon, probably after diverticulitis, and the bile duct stent that had perforated the same site. The stent was removed and endoscopic closure of the perforation was performed using an over-the-scope clip. Abdominal computed tomography 8 days after the closure showed no extraintestinal gas. The patient resumed eating and was discharged on the 14th day of admission. There was no recurrence of abdominal pain. Endoscopic closure of sigmoid colon perforation due to bile duct stent migration using an over-the-scope clip has not been reported thus far, and it may be a new treatment option in the future. [ABSTRACT FROM AUTHOR]

Iatrogenic Stapfer type-1 duodenal perforations during endoscopic retrograde cholangiopancreatography (ERCP) typically necessitate surgical management and carry significant morbidity and mortality risk. Here, we present a case of a large duodenal perforation during ERCP managed endoscopically with an over-the-scope clip (OTSC) and describe the subsequent post-procedural management. An 80-year-old woman presented to the emergency department with acute cholangitis. Abdominal ultrasound scan revealed a dilated biliary tree with echogenic material in the common hepatic and intrahepatic ducts. The patient proceeded to ERCP, where filling defects consistent with stones were found in the proximal main bile duct on cholangiogram. Stone retrieval was complicated by a large iatrogenic perforation of the infero-lateral duodenal wall, distal to the major ampulla (Stapfer type-1). Following unsuccessful attempts to close the defect using through-the-scope clips, a decision was made to attempt closure endoscopically using an OTSC. The duodenoscope was exchanged for a forward-viewing gastroscope mounted with the OTSC. The perforation defect was fully suctioned into the cap and the clip was successfully deployed. Subsequent on-table fluoroscopy with contrast injection did not demonstrate any extra-luminal contrast leak. The patient developed a post-procedure infra-duodenal collection, however, made a complete recovery with bowel rest, negative pressure regulation at the site of the OTSC using a dual-lumen nasogastric/nasojejunal feeding tube and intravenous piperacillin-tazobactam. Thus, OTSCs potentially offer a safe and effective endoscopic treatment modality for the immediate management of ERCP-related Stapfer type-1 duodenal perforations. [ABSTRACT FROM AUTHOR]

Over-the-scope clip (OTSC) is widely used in clinics for the treatment of iatrogenic perforations and fistulas and for hemostasis. The aim of this study was to retrospectively evaluate cases applied with the over-the-scope clip for gastrointestinal fistula or leakage. The study included patients on whom over-the-scope clip was performed because of leakage or fistula in the gastroenterology surgery endoscopy unit between June 2016 and January 2020. The cases were evaluated in terms of age, gender, diagnosis, localization of the defect, additional disease, size of the defect, procedure success, clinical success, number of clips, time of over-the-scope-clip application after the first procedure and duration of follow-up. In 9 patients, 11 over-the-scope clips were used. The procedure was performed in the upper gastrointestinal tract in 5 (55.56%) cases and in the lower gastrointestinal tract in 4 (44.44%) cases. Technical success was achieved in all 11 procedures performed in 9 cases. Long-term clinical success was achieved in 8 of 9 cases. The over-the-scope clip is an endoscopic method that can be used safely in the treatment of gastrointestinal fistulas and leakage of < 1 cm with a low possibility of morbidity and a high success rate. [ABSTRACT FROM AUTHOR]

There are several reports on the use of the over-the-scope clip (OTSC) for gastrointestinal bleeding/fistula and endoscopic iatrogenic perforation. However, there are almost no reports on OTSC use for anastomotic leakage (AL) after colorectal cancer surgery. The purpose of this study was to evaluate the outcome of AL closure using the OTSC. Five patients who had undergone AL after laparoscopic surgery for colorectal cancer from April 2017 to April 2019 were evaluated. The average distance from the anal verge of the anastomosis site was 12 (5–18) cm. The average diameter of the dehiscent part was 10.9 (9.3–14.4) mm. The average number of OTSC days after the occurrence of AL was 11 (5–22). On the contrast examination immediately after OTSC, all cases were completely closed, but in the later contrast examination, only one case remained completely closed. The average incompletely closed diameter was 3.6 (2.9–5.1) mm, and the diameter of the dehiscent part was reduced in all cases. Only one patient ultimately underwent colostomy; the rest were cured with OTSC alone. AL site closure using the OTSC after colorectal cancer surgery is a useful minimally invasive treatment when combined with appropriate drain management. [ABSTRACT FROM AUTHOR]

Tracheoesophageal fistulas (TEFs) have traditionally been managed surgically, but the endoscopic approach is widely performed as a less invasive alternative. Different closure techniques have been proposed with inconsistent results. An over-the-scope clip (OTSC) appears to be a reasonable option, but long-term results have not been well defined. We report the long-term outcomes of a complex case of successful closure of a benign refractory TEF using an OTSC after failed surgical management and esophageal stent placement.

Nonvariceal upper gastrointestinal hemorrhage (NVUGIH) is more prevalent than lower gastrointestinal hemorrhage and carries a high risk of mortality in the elderly, especially those with significant cardiovascular comorbidities. Traditional endoscopic methods, such as through-the-scope clips, electrocautery, and epinephrine injection, are frequently used to control these bleeds; however, they carry a 10% risk of rebleeding, and this itself carries a mortality risk of 36%. The larger over-the-scope clips (OTSC) that were initially used for the closure of fistulas and perforations are now gradually being implemented to manage NVUGIH. To our knowledge, we present the first cases to be reported in the literature where OTSC was successfully used as salvage therapy for refractory acute upper gastrointestinal bleeders who failed traditional endoscopic management and interventional radiology-guided embolization of the bleeding artery. We also provide an up-to-date literature review on the use of OTSC and its superiority to traditional endoscopic interventions in the management of complicated NVUGIH.

Abstract Background Conventional endoscopic treatments can’t control bleeding in as many as 20% of patients with non-variceal gastrointestinal (GI) bleeding. Recent studies have shown that over-the-scope-clip (OTSC) system allowed for effective hemostasis for refractory GI bleeding lesions. So we aimed to conduct a systematic review to evaluate the effectiveness and safety of the OTSC system for management of acute non-variceal upper GI bleeding. Method A comprehensive literature search was conducted on PubMed, EMBASE, and Cochrane Library covering the period from January 2007 to May 2019. The literature was selected independently by two reviewers according to the inclusion and exclusion criteria. The statistical analysis was carried out using Comprehensive Meta-Analysis software version 3.0. Results A total of 16 studies including 769 patients with 778 GI bleeding lesions were identified. Pooled technical success was achieved in 761 lesions [95.7%; 95% confidence interval (CI), 93.5–97.2%], and the pooled clinical success was achieved in 666 lesions (84.2, 95% CI, 77.4–89.2%). The incidence of re-bleeding was reported in 81 patients and the post-procedure mortality was 10.9% (n = 84). Only 2 (0.3%) patients occurred complications after OTSC system procedure. Conclusions Our study demonstrated that the OTSC system was a technically feasible modality and highly efficacious in achieving hemostasis in acute non-variceal upper gastrointestinal bleeding.

Colovesical fistula (CVF) is an abnormal communication between bowel and urinary bladder. Most common cause is complicated colonic diverticular disease. The treatment of choice for CVF is surgery. Conservative treatment is reserved for highly selected patients who are unfit for definitive surgery. We report the case of an 86-year-old gentleman with multiple comorbidities, who presented with pneumaturia, fecaluria, and recurrent urinary tract infection. He was diagnosed to have sigmoid colonic diverticulosis with a CVF and was successfully managed with the novel combined endoscopic approach (a simultaneous cystoscopy and flexible colonoscopy), which could be the first to be reported from India.

While perforations, postoperative fistulas, and leaks have traditionally led to surgical or interventional radiology consultation for management, the introduction of the over-the-scope clip has allowed increased therapeutic possibilities for endoscopists. While primarily limited to case reports and series, the over-the-scope clip successfully manages gastrointestinal bleeding, perforations, as well as postoperative leaks and fistulas. Retrospective studies have demonstrated a relatively high success rate and a low complication rate. Given the similarity to variceal banding equipment, the learning curve with the over-the-scope clip is rapid. However, given the higher risk of procedures involving the use of the over-the-scope clip, it is essential to obtain the scope in a stable position and grasp sufficient tissue with the cap using a grasping tool and/or suction. From our experience, while closure may be successful in lesions sized up to 3 cm, successful outcomes are obtained for lesions sized <1 cm. Ultimately, given the limited available data, prospective randomized trials are needed to better evaluate the utility of the over-the-scope clip in various clinical scenarios, including fistula and perforation management. [ABSTRACT FROM AUTHOR]

A 76-year-old man diagnosed with early-stage colorectal cancer was referred to our hospital for endoscopic submucosal dissection (ESD). The patient had a low platelet count (31,000/µL) due to immune thrombocytopenia (ITP). The cancerous lesion was completely resected without any adverse events. A blood test performed 1 day post-ESD showed no progression of anemia and the initial postoperative course was uneventful. However, 7 days after ESD, dark red stools were observed, and we performed an emergency colonoscopy. We stopped the bleeding twice using hemoclips and hemostatic forceps. Since the patient's platelet count remained below 50,000/µL, we started thrombopoietin receptor agonist treatment with eltrombopag (12.5 mg/day) for thrombocytopenia. Although the platelet count increased, the patient experienced rebleeding for the fourth time and underwent an emergency colonoscopy, during which we used an over-the-scope clip (OTSC) to achieve hemostasis. No rebleeding occurred after OTSC intervention, and the platelet count stabilized at approximately 50,000/µL. We discharged the patient on Day 34 after ESD. Although the guidelines do not specify a target platelet count for performing ESD, a platelet count < 50,000/µL should be considered low. Furthermore, an OTSC may be useful for treating intractable bleeding. [ABSTRACT FROM AUTHOR]

Background/Aims: The Padlock clip is a recently introduced over-the-scope clip (OTSC) that requires the use of an alternate technique and has a different design from previous OTSCs. However, data regarding its clinical use are limited. The aim of this study is to present our clinical experience using this novel Padlock clip system. Methods: Between September 2018 and June 2019, 7 consecutive patients underwent Padlock clip application at our center by an experienced endoscopist. A Padlock clip was used for achieving hemostasis in 4 patients presenting with gastrointestinal (GI) bleeding, as well as for endoscopic full-thickness resection in the remaining 3 patients. Results: All 7 patients achieved technical as well as clinical success, with absence of complications or rebleeding, during a follow-up of a minimum of 3 weeks. All patients were hospitalized post procedure for a minimum of 48 hours, and an absence of adverse events was noted in our patient population throughout the procedure and post-procedure period. Antiplatelet therapy was reinstated shortly after the application of the Padlock clip, with no GI bleeding observed. Conclusions: The Padlock clip is a novel OTSC, with benefits that include safe, simple, and rapid deployment. Antiplatelet therapy may be reinstated for patients, when necessary, shortly after applying the Padlock clip due to full-thickness closure of the tissue.

Lateral duodenal wall perforation occurring during endoscopic retrograde cholangiopancreatography (ERCP) due to scope trauma is large and usually treated by surgery. With advances in endoscopic instrumentation, interest in treating these complications using endoscopic devices has increased. Over-the-scope clip (OTSC) which has higher compression force and can approximate large perforations is being increasingly used for the closure of gastrointestinal fistulae and perforations. We recently used OTSC for treating duodenal perforations which occurred during ERCP in two elderly patients. Both these patients had comorbid conditions and were high risk for surgery. Perforations were immediately identified during endoscopy and were closed with OTSC. Both patients had uneventful further course and were discharged successfully. These cases highlight the usefulness of OTSC for the management of endoscopic duodenal perforations.

Bariatric surgery has rapidly emerged as a modality for managing morbid obesity; however, despite being considered safe, some complications do exist. Formation of a gastrobronchial fistula is a rare complication of laparoscopic sleeve gastrectomy that is associated with high morbidity and mortality. Nowadays, novel endoscopic techniques have widely been adopted in the management of such cases, as they provide minimally invasive options that decrease the morbidity and mortality. Here, the author presents a report of a middle-aged, morbidly obese male who had previously undergone laparoscopic sleeve gastrectomy and returned with a 3-month history of productive cough. On upper gastrointestinal series, the patient was found to have a fistula communicating the stomach to the bronchial tree of his left lung (gastrobronchial fistula). He was treated with endoscopic fistula closure using an over-the-scope clip and a fully-covered Niti-S metallic stent. After this treatment, the patient's symptoms improved dramatically, and the stent was successfully removed 12 weeks later. This report highlights the management of a patient with gastrobronchial fistula formation following laparoscopic sleeve gastrectomy as well as provides a literature review of using combined endoscopic management to treat gastrobronchial fistulas.

Management of iatrogenic gastrointestinal (GI) defects traditionally required surgical interventions. Recently, the over-the-scope-clip system (OTSC) has been reported to be effective for GI defects. So we aimed to conduct an updated systematic review to evaluate the clinical safety and efficacy of the OTSC system for the management of iatrogenic GI defects. Studies published in PubMed, Embase and Cochrane library from January 2006 to December 2018 were searched. The literature was selected independently by two reviewers according to inclusion and exclusion criteria. The statistical analysis was carried out using Comprehensive Meta-Analysis software version 3.0. A total of 12 studies including 191 patients with iatrogenic GI defects were identified. The major causes for iatrogenic GI defects were endoscopic submucosal dissection (n = 79) and endoscopic mucosal resection (n = 31). Pooled technical success was achieved in 182 patients (89.1%; 95% confidence interval (CI), 81.6%-93.8%, I2 =41.06%), and the pooled clinical success was achieved in 170 patients (85.2%; 95% CI, 71.9%–92.8%, I2=58.92%). Two patients (1%) suffered complications after OTSC system procedures. Our study revealed that endoscopic closure of iatrogenic GI defects by the OTSC system was a safe and effective approach. Further randomized controlled trials are warranted to compare the OTSC system to other treatment modalities. [ABSTRACT FROM AUTHOR]

Objectives: This study was aimed to reveal risk factors for delayed bleeding after endoscopic resection (ER) of superficial non‐ampullary duodenal epithelial tumors (SNADETs) and at exploring measures to prevent this complication. Methods: A total of 235 consecutive patients with 249 SNADETs who had undergone ER were enrolled in this study. They were divided into two groups: OTSC group, consisting of the initial 114 cases in which the defects were closed only using OTSCs; and OTSC‐c group, consisting of the later 135 cases in which conventional clips were additionally used to cover the inverted submucosa after post‐procedure defect closure using OTSCs. The therapeutic outcomes were then compared between the OTSC and OTSC‐c groups. Results: All lesions were successfully resected en‐bloc, and the R0 resection rate was 92.4%. The complete defect closure rate was 90.0% and no delayed perforation occurred when successful defect closure was achieved. The rate of delayed bleeding was significantly higher in the OTSC group than in OTSC‐c group (11.4% vs. 1.5%, P = 0.001). Multivariate logistic regression analyses revealed that tumor location distal to the ampulla (OR 10.0; 95% CI 1.24–81.0, P = 0.03) and use of a DOAC (OR 8.83; 95% CI 1.13–68.7, P = 0.04) were significant independent predictors of delayed bleeding. Propensity score‐matching analysis revealed that additional use of conventional clips was associated with a significantly reduced risk of delayed bleeding (P = 0.003). Conclusions: Additional use of conventional clips after prophylactic defect closure using OTSCs appears to be useful to reduce the risk of delayed bleeding after ER of SNADETs. UMIN Clinical Trials (No. 000035478). [ABSTRACT FROM AUTHOR]

Gastropleural fistula (GPF) is a rare pathological communication between the stomach and pleura. It may complicate sleeve gastrectomy (SG). An endoscopic application of OTSC can be used to manage GPF. [ABSTRACT FROM AUTHOR]

Purpose of review: We review the latest advances in management of peptic ulcer bleeding and the updates from international guidelines. Recent findings: A low Glasgow Blatchford score of ≤ 1 can safely identify low-risk patients to manage in out-patient settings. Except patients with persistent haemodynamic instability, early endoscopy within 24 h appears safe when compared with earlier intervention. Over-the-scope-clips (OTSC) show promising result as first-line and second-line endoscopic haemostaic therapy, while haemostatic spray can be considered as a stop-gap treatment. After endoscopic intervention, high-dose oral proton-pump-inhibitor (PPI) is an alternative to intravenous use in selected cases. Retrospective data shows new-generation P2Y12 inhibitors (prasugrel and ticagrelor) have higher risk of bleeding when compared with clopidogrel. Vonoprazan, a potassium-competitive acid blocker and a potent acid suppressor, shows encouraging initial results in management of gastrointestinal bleeding. Summary: Endoscopic therapy remains the mainstay of treatment of peptic ulcer bleeding and future research will clarify the role of new endoscopic treatment modalities such as OTSC. Good peri-endoscopic treatment remains crucial, and more data is needed to guide management in patients on new generation anti-platelet drugs and direct oral anti-coagulants. [ABSTRACT FROM AUTHOR]

Purpose: The over-the-scope clip (OTSC) enables non-surgical management of gastrointestinal defects. The aim of this study was to report our experience with OTSC for patients with staple line leaks following laparoscopic sleeve gastrectomy (LSG). Materials and Methods: A prospectively maintained IRB-approved institutional database was queried for all patients treated with OTSC for staple line leaks following LSG from 2010 to 2018. Primary outcome was complete resolution of leak following OTSC. Secondary outcome was the number of additional procedures needed following OTSC. Results: Twenty-six patients (13 males, 13 females) were treated with OTSC for staple line leaks following LSG. The median age was 35 years (range 18–62), and mean body mass index was 44 kg/m2. The median time from index operation to leak diagnosis and from leak diagnosis to OTSC was 18 days (range 2–118), and 6 days (range 1–120), respectively. The initial endoscopic treatment was OTSC (n = 19), stent (n = 5), clip (n = 1), and clip and biologic glue (n = 1). OTSC alone led to final resolution of leak in 8 patients (31%) within 43 days of clip deployment (range 5–87). Five leaks resolved after a combination of OTSC and stent (19%) and one leak (4%) resolved after endoscopic suturing following a failed OTSC. Eleven patients (42%) failed endoscopic management and underwent total gastrectomy and esophagojejunostomy. One mortality (4%) was noted. The number of additional endoscopic sessions ranged from 1 to 10 (median 2). Conclusions: OTSC carries a low success rate for controlling staple line leaks following LSG. [ABSTRACT FROM AUTHOR]

Objective: Relevant publications were identified by searching PubMed, EMBASE, Cochrane Central Register of Controlled Trials and Web of Science before December 1, 2019. Studies in which ≥ 10 cases of colorectal lesions were resected with endoscopic full-thickness resection (EFTR) were included. Rates of efficacy (technical success (en bloc), full-thickness resection and R0 resection), rates of safety (bleeding, perforation and postpolypectomy syndrome) and rates of follow-up (residual/recurrent adenoma, fate of over-the-scope clip and surgery for any reason) were pooled and analyzed. Forest plots were graphed based on random effects models. Subgroup analyses and sensitivity analyses were also performed if significant heterogeneity existed. Results: A total of 469 patients across 9 studies were eligible for analysis. The pooled rates of technical success, full-thickness resection and R0 resection were 94.0% (95% CI 89.8–97.3%), 89.5% (83.9–94.2%) and 84.9% (75.1–92.8%), respectively. The pooled estimates of bleeding, perforation and postpolypectomy syndrome were 2.2% (95% CI 0.4–4.9%), 0.19% (95% CI 0.00–1.25%) and 2.3% (95% CI 0.1–6.3%), respectively. Finally, the pooled rates of residual/recurrent adenoma, fate of OTSC and surgery for any reason were 8.5% (95% CI 4.1–14.0%), 80.3% (95% CI 67.5–90.8%) and 6.3% (2.4–11.7%), respectively. Conclusions: EFTR for nonlifting, invasive lesions in the colon and rectum appears to be effective and safe. However, future studies are necessary to explore the role of EFTR in large colorectal lesions and specify its indications. [ABSTRACT FROM AUTHOR]

Copyright of Turkish Journal of Trauma & Emergency Surgery / Ulusal Travma ve Acil Cerrahi Dergisi is the property of KARE Publishing and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background and study aim: This study aimed to assess the safety and feasibility of endoscopic submucosal dissection (ESD) using a scissors‐type knife with prophylactic closure using over‐the‐scope clip (OTSC) for superficial non‐ampullary duodenal epithelial tumors (SNADETs). Patients and methods: Consecutive patients who underwent ESD for SNADETs >10 mm between January 2009 and July 2019 were retrospectively enrolled. We performed ESD using either a needle‐type knife (Flush Knife‐ESD) or a scissors‐type knife (Clutch Cutter‐ESD). Mucosal defects were prophylactically closed using three methods: conventional clip, laparoscopic closure, or OTSC. Results: A total of 84 lesions were resected using the Flush Knife‐ESD and the Clutch Cutter‐ESD (37 and 47 patients, respectively), and conventional clip, laparoscopic closure, and OTSC for mucosal defect closure after ESD were applied in 13, 13, and 56 lesions, respectively. The R0 resection rate was significantly higher in the Clutch Cutter‐ESD than that in the Flush Knife‐ESD (97.9% vs 83.8%, respectively, P = 0.040). The intraoperative perforation rate was significantly lower in the Clutch Cutter‐ESD than in the Flush Knife‐ESD (0% vs 13.5%, respectively, P = 0.014). Complete closure rates of conventional clip, laparoscopic closure, and OTSC were 76.9%, 92.3%, and 98.2%, respectively (P = 0.021); and delayed perforation rates were 15.4%, 7.7%, and 1.8%, respectively (P = 0.092). Conclusions: Endoscopic submucosal dissection using a scissors‐type knife with prophylactic OTSC closure is safe and feasible for the low‐invasive treatment of SNADETs. [ABSTRACT FROM AUTHOR]

Copyright of Der Gastroenterologe is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Background: In the management of mucosal neoplasm and early cancer, therapeutic gastrointestinal endoscopy evolved from simply polypectomy, endoscopic mucosal resection, endoscopic submucosal dissection (ESD), to endoscopic full thickness resection (EFTR). Full thickness clip closure followed by transmural resection mimics surgical principles. It is safe, effective, and technically less demanding compared to other techniques. Over-the-scope clip (OTSC)-assisted EFTR or OTSC-EFTR enables the endoscopists to manage difficult lesions.Methods: We video recorded and report our 1-year single center experience of 12 consecutive EFTR cases since the dedicated OTSC-EFTR device was approved in the USA.Results: We demonstrate that OTSC-EFTR can be very useful to manage residual neoplastic tissue that cannot be removed during conventional mucosal resection due to deeper invasion, submucosal fibrosis, scaring from prior intervention, and appendiceal involvement. Caution should be used for EFTR of the ileocecal valve lesions.Conclusion: We propose that layered or stacked biopsy of the appendiceal stump after EFTR should be performed to rule out a positive residual base. Due to the limited size of the FTRD resection hood (13 mm internal diameter × 23 mm depth), for larger sessile adenomas in the colon, we propose a hybrid approach for complete removal: piecemeal EMR for tumor debulking followed by OTSC-EFTR to achieve R0 resection. We believe OTSC-EFTR offers safety and efficiency with very high success rate. [ABSTRACT FROM AUTHOR]

Background: Endoscopic management of full-thickness gastrointestinal tract defects (FTGID) has become an attractive management strategy, as it avoids the morbidity of surgery. We have previously described the short-term outcomes of over-the-scope clip management of 22 patients with non-acute FTGID. This study updates our prior findings with a larger sample size and longer follow-up period.Methods: A retrospective analysis of prospectively collected data was conducted. All patients undergoing over-the-scope clip management of FTGID between 2013 and 2019 were identified. Acute perforations immediately managed and FTGID requiring endoscopic suturing were excluded. Patient demographics, endoscopic adjunct therapies, number of endoscopic interventions, and need for operative management were evaluated. Success was strictly defined as complete FTGID closure.Results: We identified 92 patients with 117 FTGID (65 fistulae and 52 leaks); 27.2% had more than one FTGID managed simultaneously. The OTSC device (Ovesco Endoscopy, Tubingen, Germany) was utilized in all cases. Additional closure attempts were required in 22.2% of defects. With a median follow-up period of 5.5 months, overall defect closure success rate was 66.1% (55.0% fistulae vs. 79.6% leaks, p = 0.007). There were four mortalities from causes unrelated to the FTGID. Only 14.9% of patients with FTGID underwent operative management. There were no complications related to endoscopic intervention and no patients required urgent surgical intervention.Conclusions: Over-the-scope clip management of FTGID represents a safe alternative to potentially morbid operative intervention. When strictly defining success as complete closure of all FTGID, endoscopy was successful in 64.4% of patients with only a small minority of patients ultimately requiring surgery. [ABSTRACT FROM AUTHOR]

Nonvariceal upper gastrointestinal hemorrhage (NVUGIH) is more prevalent than lower gastrointestinal hemorrhage and carries a high risk of mortality in the elderly, especially those with significant cardiovascular comorbidities. Traditional endoscopic methods, such as through-the-scope clips, electrocautery, and epinephrine injection, are frequently used to control these bleeds; however, they carry a 10% risk of rebleeding, and this itself carries a mortality risk of 36%. The larger over-the-scope clips (OTSC) that were initially used for the closure of fistulas and perforations are now gradually being implemented to manage NVUGIH. To our knowledge, we present the first cases to be reported in the literature where OTSC was successfully used as salvage therapy for refractory acute upper gastrointestinal bleeders who failed traditional endoscopic management and interventional radiology-guided embolization of the bleeding artery. We also provide an up-to-date literature review on the use of OTSC and its superiority to traditional endoscopic interventions in the management of complicated NVUGIH. [ABSTRACT FROM AUTHOR]