David J Morrell, MD1, Joshua S Winder, MD1, Ansh Johri, MS2, Vamsi V Alli, MD1, Eric M Pauli, MD1. 1Penn State Health Milton S. Hershey Medical Center, 2The Pennsylvania State University College of Medicine
Introduction: Given the morbidity of reoperation, endoscopic management of full-thickness gastrointestinal tract defects (FTGID) has become an attractive management strategy. We have previously described the short-term outcomes of over-the-scope clip (OTSC) management of 22 patients with FTGID reporting an overall success rate of 82% (100% for leaks, 76% for fistulae, median follow-up 4.7 months). This study updates our prior findings with a larger sample size and longer follow-up period.
Methods: A retrospective analysis of prospectively collected data was conducted. All patients undergoing OTSC management of FTGID between 2013-2018 were identified. Acute perforations managed immediately and FTGID requiring endoscopic suturing were excluded. Patient demographics, endoscopic adjunct therapies, number of endoscopic interventions, and need for operative management were evaluated. Success was strictly defined as complete closure. Successful FTGID closures were stratified and compared using chi-squared and Student’s t-tests.
Results: We identified 84 patients with 107 FTGID (68 foregut, 17 small bowel, and 22 colorectal including 60 fistulae and 47 leaks); 19% had more than one FTGID managed simultaneously. The OTSC (Ovesco Endoscopy, Germany) was utilized in all cases. Endoscopic adjuncts were utilized in 81.3% of cases (foreign body removal 18.7%, mucosal ablation 51.4%, management of distal obstruction 10.3%, endoscopic feeding access 16.8%, and endoscopic drain repositioning 17.8%). Three patients had incomplete FTGID closure noted immediately intraoperatively. Additional closure attempts were required in 22.6% of patients. With a mean follow-up period of 10 months, overall closure success rate was 65.7% (58.2% fistulae vs. 75% leaks, p=0.08). Patient characteristics associated with failure included diabetes (32.35% of failures vs. 10.94% of successes, p=0.008), prior smoking (64.71% vs. 29.69%, p=0.001) and prior radiation treatment (11.76% vs. 1.56%, p=0.027). We identified no statistically significant difference in success when comparing defect characteristics (size, location, age) or intervention details, although prior OTSC intervention was associated with failure (8.82% vs 0%, p=0.015). There were 4 mortalities from causes unrelated to the FTGID. Only 14.95% of patients required FTGID operative management. There were no complications related to endoscopic intervention and no patients required urgent surgical intervention.
Conclusions: OTSC management of FTGID represents a safe alternative to potentially morbid operative intervention. When considering only complete defect closure as ‘success,’ 65.7% of patients were successfully managed. However, only a small minority of patients ultimately required surgery. Patient comorbidities appear predictive of long-term outcome. Further study is needed to identify predictors of long-term closure.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 95006
Program Number: S148
Presentation Session: Flexible Endoscopy II
Presentation Type: Podium