P Umamaheswaran, MD, D Davila-Bradley, MD, A Bastawrous, MD, D Schembre, MD, R Kratz, MD, J A Cervera-Servin, MD, R W Aye, MD, B E Louie, MD. Swedish Medical Center.
Introduction: Gastrointestinal fistulas and perforations can be challenging problems for surgeons and endoscopists. Traditional management was surgical if the patient was systemically unwell or nil per os combined with image-guided drainage and supportive care if stable. A new over-the-scope clip (OTSC) has shown promise in closing perforations or post operative fistulas thus avoiding the need for repeat surgical intervention. The purpose of our study is to determine the clinical and radiological success of the OTSC during conservative management of post-operative fistulas, leaks and perforations after bariatric, foregut and colorectal surgery.
Methods: We performed a retrospective review of patients with spontaneous anastomotic fistulas, rectovaginal fistulas (RVF), or iatrogenic perforations that had OTSC clips placed as primary treatment between Jan 2011 to the August 2013. The OTSC clips are placed endoscopically and the patients were followed clinically. Data was collected from hospital records to include technical success in deployment, clinical improvement in symptoms, radiological evidence of fistula improvement subsequent imaging, and complications associated with the OTSC.
Results: Twenty-one patients underwent OTSC clip placement: 11 in the upper gastrointestinal tract (UGIT) and 10 in the lower gastrointestinal tract (LGIT). In the UGIT, 4 were for acute endoscopic perforations (3 ERCP and 1 endoscopic drainage of a periduodenal fluid collection), 2 for acute surgical leaks (POD 4 and 7) after laparoscopic Roux-en-Y gastric bypass and 5 for chronic esophageal/gastric fistulas (4 after sleeve gastrectomy and 1 after revision of gastro-gastric fistula). In the LGIT, 2 were spontaneous colonic fistulas after severe necrotizing pancreatitis, 3 were RVFs after postoperative injuries, and 5 were anastomotic fistulas (4 after a low anterior resection, and 1 after repair of a rectosigmoid injury following a salphingooopherectomy). The two spontaneous colonic fistulas did not have follow-up imaging to assess radiologic success of fistula closure.
Deployment was not successful in three patients secondary to acute angulation of the LGI fistula tract (duration = 58d), rigidity of the LGI fistula tract wall (duration = 186d), and technical difficulty with OTSC getting caught in the three-pronged grasper (duration = 32d). Clinical success did not occur in 2 LGIT anastomotic fistulas, 1 acute leak after gastric bypass and 2 chronic fistulas after sleeve gastrectomy. One UGI fistula enlarged after 2 clips were placed onto the same fistula tract necessitating removal and continued nil per os and external drainage till healed.
Conclusions: The placement of OTSC clips is a novel approach to the treatment of gastrointestinal perforations and fistulas. Even though radiologic success is not always evident, clinical improvement of symptoms is achieved in over 70% of cases. The majority of clinical failures are in those patients with chronic fistulas, and are likely attributed to epithelialization, ischemia and persistent infection.