Iatrogenic perforations of the GI tract are rare but can occur during diagnostic or interventional endoscopy. Early recognition, localization and evaluation of the severity of injury are mandatory to direct possible endoscopic treatment. Several endoscopic techniques have been used successfully to achieve closure of these injuries: standard hemostatic clips, modified over the scope clips such as an OVESCO clip with omentoplasty, fully covered metal stents, hybrid techniques combining the use of an endoloop and clips and even the use of more sophisticated endoscopic suturing systems (e.g., Overstitch®). While treating an iatrogenic defect some key points need to be kept in mind: switch to CO2 insufflation; decompress any tension pneumoperitoneum or pneumothorax; keep the patient fasting; use a nasogastric tube for continuous aspiration if needed; start broad-spectrum antibiotics; hospitalize the patient with prompt surgical consultation; and use CT scan to estimate your subsequent treatments success.

Leaks and fistulas are one of the most prominent causes of post-surgical morbidity and mortality and are considered major surgical complications. Surgical or percutaneous drainage coupled with control of the leak by means of a self expandable metal stent (SEMS) is currently the most frequent treatment. The success rate with stenting depends greatly on the duration of delay to intervention. Moreover, the use of stents is predominantly hindered by a high migration rate and occlusion by tissue ingrowth. Hemostatic clips, over-the-scope clips, glue, biodegradable plugs, endoscopic internal drainage by trans-orificeal double plastic pigtail stents and endoluminal vacuum therapy have all been proposed as valid alternative endoscopic techniques. However the most common limitation of using clips of any kind is the fibrosis and rigidity of the perforation edges, making approximation of the defect’s margins nearly impossible. To improve outcomes a close cooperation between endoscopist, surgeon and interventional radiologist is required, keeping in mind that multiple intervention sessions may be necessary.