Overview
Definition:
The Over-the-Scope Clip (OTSC) is a device deployed endoscopically to achieve hemostasis or closure of gastrointestinal defects, such as perforations or fistulas
Surgical backup refers to the planned or emergent surgical intervention that may be required when endoscopic management with OTSC is unsuccessful, contraindicated, or complicated.
Epidemiology:
OTSC is increasingly utilized for challenging endoscopic hemostasis and defect closure
Its use is indicated in a spectrum of gastrointestinal pathology from benign to malignant
Data on the specific incidence of requiring surgical backup post-OTSC is evolving but is crucial for risk stratification and resource planning.
Clinical Significance:
Effective management of gastrointestinal bleeding, perforations, and other defects is vital for patient outcomes
OTSC offers a less invasive alternative to surgery in many cases
Understanding when OTSC may fail and the necessary surgical backup strategies is paramount for surgeons and endoscopists to ensure patient safety and optimize treatment pathways, directly impacting DNB and NEET SS exam preparation.
Indications For Otsc And Need For Surgical Backup
Indications For Otsc:
Active arterial bleeding from peptic ulcers
Post-polypectomy bleeding refractory to other methods
Gastrointestinal perforations (e.g., iatrogenic, diverticular)
Esophageal or gastric fistula closure
Management of Dieulafoy's lesions.
Considerations For Surgical Backup:
Failure of OTSC deployment or closure
Inability to achieve adequate hemostasis or seal
Significant associated bleeding requiring transfusion or hemodynamic instability
Large or complex perforations not amenable to endoscopic closure
Patient comorbidities precluding further endoscopic attempts
Suspected or confirmed OTSC dislodgement or malapposition.
Decision Making Algorithm:
Assess patient stability
Evaluate lesion size and depth
Consider lesion location and surrounding anatomy
Perform diagnostic endoscopy
Attempt OTSC deployment
If successful and stable, monitor
If unsuccessful or unstable, proceed to surgical consultation and backup plan.
Otsc Deployment And Technique
Preoperative Preparation:
Fasting
IV access
Review of anticoagulation status
Informed consent detailing potential need for surgery
Endoscopic visualization and cleaning of the target area.
Otsc System Components:
The OTSC system consists of a flexible applicator cap, a sterile OTSC device (clip), and a delivery system
Different OTSC sizes and shapes are available for various indications.
Deployment Technique:
The target tissue is aspirated into the applicator cap using the integrated suction
The OTSC is then triggered, grasping and approximating the tissue edges
Visual confirmation of clip capture and closure is essential
Secure capture of a sufficient amount of tissue (mucosa and submucosa) is critical for efficacy and to prevent dislodgement
Careful retraction of the delivery system ensures the clip remains in place.
Surgical Backup Procedures And Management
Indications For Immediate Surgery:
Hemodynamic instability despite resuscitation
OTSC failure leading to ongoing massive hemorrhage
Evidence of widespread contamination from a large perforation
Inability to re-attempt endoscopic closure safely.
Surgical Approaches:
Laparotomy or laparoscopy may be employed
For bleeding, ligation, resection, or suture closure of the bleeding source
For perforations, repair, resection with diversion (e.g., ostomy), or primary closure depending on the location, size, and contamination
Management of the OTSC itself may involve laparoscopic or open removal if it is causing obstruction or is otherwise problematic.
Postoperative Care:
Intensive monitoring in an ICU setting
Fluid and electrolyte management
Antibiotic therapy for contamination
Nutritional support (parenteral or enteral)
Pain management
Gradual resumption of oral intake
Close follow-up for complications.
Challenges In Surgical Management:
Adhesions from previous procedures
Difficulty in identifying the exact site of perforation or bleeding endoscopically
Managing contamination and sepsis
Presence of the OTSC device itself can sometimes complicate surgical access or repair.
Complications And Troubleshooting
Otsc Related Complications:
Failure to deploy
Inadequate tissue capture
Clip dislodgement
Bleeding post-deployment
Perforation secondary to deployment
Obstruction
Pain.
Surgical Backup Related Complications:
Standard surgical risks: infection, bleeding, dehiscence, fistula formation, ileus, intra-abdominal abscess
Specific to OTSC backup: difficulty in accessing the lesion due to the clip, mechanical obstruction by the clip.
Troubleshooting And Prevention:
Careful lesion selection and patient assessment
Adequate training in OTSC deployment
Ensuring sufficient tissue capture
Maintaining appropriate suction during deployment
Having a clear surgical backup plan and readily available surgical team
Prompt recognition of OTSC failure or complications.
Key Points
Exam Focus:
Understand the indications for OTSC use and the critical parameters for its success
Be prepared to identify scenarios requiring immediate surgical intervention post-OTSC attempt
Recognize potential surgical backup procedures for bleeding and perforation management.
Clinical Pearls:
Always have a surgical consultant readily available when attempting OTSC for high-risk lesions
Document OTSC deployment meticulously, including the number of attempts and visual confirmation of closure
Consider the OTSC as a tool, not a definitive solution, and be prepared for failure.
Common Mistakes:
Attempting OTSC on lesions too large or deep for adequate capture
Inadequate tissue aspiration into the cap
Not confirming clip closure visually
Delaying surgical consultation when OTSC fails or complications arise
Misinterpreting patient instability as solely related to the underlying pathology without considering OTSC-related issues.