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A 46-year-old man with end-stage renal disease and a surgical history of three kidney transplants underwent colonoscopy to assess eligibility for retransplantation. Water exchange CO2-insufflated colonoscopy was performed under deep sedation. After traversing about 50 cm of the fixed and acutely angulated sigmoid colon, an iatrogenic perforation was promptly recognized: a transmural wall defect 20mm in diameter (▶Fig. 1). Broad-spectrum antibiotic therapy was started. After a prompt multidisciplinary evaluation, immediate endoscopic closure under general anesthesia was planned (▶Video 1). The perforation site was reached with a double-channel endoscope (GIF2T160; Olympus Europe, Hamburg, Germany). Endoscopic peritoneal exploration was done in order to rule out leaked luminal contents and visceral injuries. An angiocatheter attached to a syringe half-filled with normal saline was percutaneously inserted under direct endoscopic view for capnoperitoneum management (▶Fig. 2). A full-thickness continuous suture incorporating an omental flap was performed using the OverStitch suturing device (Apollo Endosurgery, Austin, Texas, USA), thus creating an omental patch endoscopically. The complete closure was confirmed by full luminal distension restoration and by the negative air-leak pressure test. Furthermore, neither contrast medium nor CO2 extravasation was observed on fluoroscopy. The angiocatheter was extracted after removal of all residual peritoneal gas. Over the subsequent 48 hours, broadspectrum antibiotics, fluid replacement, and fasting were prescribed. The patient remained asymptomatic: the physical examination was negative for signs of peritonitis and the bowel remained canalized. Abdominal computed tomography performed on Day 2 showed intact anastomotic site without free fluid collections (▶Fig. 3). Oral feeding was resumed, and E-Videos

Iatrogenic perforation during colonoscopy in the endoscopic suturing era: surgical emergency or endoscopic clinical practice?