James D Roy, MD, Paul Rider, MD, Leander Grimm, MD, John Hunter, MD, William Richards, MD. University of South Alabama
Enterocutaneous fistulae represent a spectrum of disease that offer plentiful challenges to surgeons. The mainstays of treatment are long term conservative management versus surgical management in typically malnourished patients with hostile abdomens. At our institution, we have begun exploring a new, minimally invasive endoscopic treatment approach known as over the scope clip closure (OTSC) to increase the surgeon’s management options. OTSC was approved for use in the United States in 2010, before which, its use was employed mainly within European health systems.
Methods and Procedures:
This was an IRB approved retrospective review of our experience. The approach to OTSC begins with endoscopically identifying the fistula. After identification, the fistulous tract is confirmed by real-time endoscopic visualization of methylene blue appearing in the lumen of the bowel after injection of the methylene blue into the cutaneous opening, which confirms the location of the fistulous tract. Following identification, the primary opening is mechanically debrided with biopsy forceps. An endoscope with OTSC system mounted is brought into interface with the primary fistulous opening while extracorporeal irrigation is continued. The mucosa is suctioned into the OTSC applicator cap, and a pre-mounted clip is fired via an external hand wheel. This process is repeated until the primary fistulous opening is closed, confirmed by the absence of methylene blue in the lumen after re-injection.
Over 26 months this technique has been applied a total of 9 times for enterocutaneous fistulae at our institution. We have experienced 6 successes and 3 failures for a success rate of 67%. In all cases, this technique was employed in patients with surgically hostile abdomens, severe comorbidities, and severe malnutrition. Our failures were in fistulae arising from two colocolonic anastomoses and one duodenal cutaneous fistula. Our successes were found in fistulae arising from two colocolonic anastomoses, one ileocolic anastomosis, one rectocolic anastomosis, one gastric wedge resection, and one loop ileostomy. The success rate from the European literature is comparable at a quoted pooled success rate of 73%.
The treatment of enterocutaneous fistulae remains difficult. OTSC affords the surgeon a minimally invasive endoscopic technique for the management of fistulae. We believe that OTSC is a valuable addition to the surgical endoscopist’s armamentarium.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 87759
Program Number: S077
Presentation Session: Flexible Endoscopy Session
Presentation Type: Podium