Strangulated Ileus Caused by Clips Used for Closure of an Appendiceal Endoscopic Submucosal Dissection Perforation: A...

Perforation developing during endoscopic submucosal dissection (ESD) for colorectal lesions can necessitate halting of the procedure and performing emergency surgery. In some cases, conservative treatment of the perforation is possible using endoscopic clips or over-the-scope-clips (OTSCs). In the case presented herein, while perforation closure was successfully achieved with conventional through-the-scope clips (hereafter referred to as "conventional clips"), the patient developed ileus as a complication, necessitating emergency surgery. The patient was a 69-year-old man who developed strangulated ileus caused by conventional clips placed for closure of a bowel perforation developing after ESD for a lesion in the cecum. We placed several conventional clips and OTSCs to close the perforation and confirmed the absence of any leak at a second-look examination. However, 10 days later, the patient visited our emergency department complaining of abdominal pain. Abdominal contrast-enhanced computed tomography revealed that a segment of the small intestine was drawn into the closing device, resulting in the development of strangulated ileus. We performed laparoscopic surgery and identified the conventional clips that had become caught in the small intestinal serosa/mesentery and led to the formation of a closed bowel loop and bowel obstruction. We released the loop without resection of the intestine. The damaged serosa and mesentery were sutured, and the patient was discharged on hospital day 8. Based on our experience, we suggest that the treating surgeon should bear in mind that even conventional clips used for perforation closure have the potential to grasp organs adjacent to the wall and cause obstruction and the development of symptoms after hospital discharge.