A Novel Endoscopic Approach to Managing High Output Entero-atmospheric Fistulae

Sean B Orenstein, MD, Yuhsin V Wu, MD, Eric M Pauli, MD, Tung T Tran, MD, Randy S Haluck, MD, Yuri W Novitsky, MD, Jeffrey M Hardacre, MD, John B Ammori, MD, Edmond Sanchez, MD, Jeffrey L Ponsky, MD, Jeffrey M Marks, MD. Department of Surgery, University Hospitals Case Medical Center, Cleveland OH; Department of Surgery, Penn State Hershey Medical Center, Hershey PA.

INTRODUCTION: Entero-atmospheric fistulae (EAF) continue to be surgical dilemmas with significant morbidity and decreased quality of life. Current non-surgical management methods have limited success with EAF closure, therefore, minimally invasive interventions are being developed for EAF management. Goals of therapy include reducing fistula output, ameliorate electrolyte and nutritional derangements, resolve infectious processes, and reduce the complex wound problems associated with EAF, thereby making patients safer candidates for definitive surgery. We present a novel endoscopic EAF management approach utilizing covered enteral stents as a bridge therapy prior to formal surgical resection.

METHODS AND PROCEDURES: Prior to procedures, the etiology of the EAF was determined and rectified or controlled (e.g. foreign body, infection, distal obstruction). Under anesthesia, a slim diagnostic endoscope was used to evaluate the small bowel proximal and distal to the EAF. With fluoroscopic guidance, a flexible-tip guidewire was positioned within each lumen. A partially or fully covered self-expanding metal enteral stent was deployed in two steps. Using Seldinger technique and fluoroscopic guidance, stent deployment began in the more tortuous limb, allowing for manual placement in the remaining, straighter, limb. The stent was fully deployed, leaving 30-50% of the stent extracorporeal. This end was collapsed utilizing the drawstring, secured with a Kelly clamp, and manually guided into the other, straighter, lumen utilizing fluoroscopy and the previously placed guidewire. Once positioned, the stent was re-expanded by releasing the clamp. The covered portion of the stent traversed the aperture of the EAF. In two patients, biologic sealant was used to cover the location of the EAF.

RESULTS: Five patients underwent stent placement for high-output EAF. Preoperatively, all five patients experienced significant skin, wound, and/or ostomy issues requiring prolonged and repeated hospitalizations and total parenteral nutritional (TPN). The mean starting fistula output was 1,577 ml/day. Four of the five patients (80%) required at least one re-intervention for stent migration, dislodgement, or incomplete seal (range:1-4 re-interventions). Post-procedure, fistula output decreased by a mean of 82% (range:56-95%; 80-530 ml/day). Subjective wound complications and management were improved. All but one patient were advanced to regular diets; three required supplemental long-term TPN. Two patients were re-admitted for wound complications secondary to the EAF. After a mean of six months (range:4-12 months) following stent placement, three patients completed definitive surgical repair with EAF takedown, stent removal, and abdominal wall reconstruction. With a mean follow up of three months, all three operative patients are doing well without recurrent fistulae.

CONCLUSIONS: Covered enteric stents can be used to control high-output EAF, reducing their associated morbidity. Wound care, TPN requirements, and oral diet tolerance were improved post-EAF stent. In three patients, the technique permitted a delay in surgery until conditions were optimal for definitive operative intervention. It is understood that this technique may necessitate multiple endoscopic interventions, as the majority of patients required revisions for stent migration/dislodgement/suboptimal EAF coverage. Further studies and alterations to current stent platforms are needed to improve this novel approach to a challenging disease.


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