Treatment of foregut fistulas with biologic fistula plugs

Rhys Filgate, Dr, Alan Thomas, Mr, Mohammed Ballal, Assoc, Professor. School of Surgery, University of Western Australia.

 Introduction
Enteric fistulas are a recognized complication of various diseases and surgical interventions. 15-25% are spontaneous and are most commonly associated with Chron’s disease, malignancy and infection. The remaining 75-85% are iatrogenic and arise most frequently as a surgical complication. They have traditionally been associated with a high risk of mortality and morbidity. Non-operative medical management will result in closure of 60-70% of all fistulas over a six to eight week period, those that fail non-operative management will require operative intervention if they are to close.
Biological materials consisting of an acellular matrix fashioned from porcine small intestine sub-mucosa stimulate fibroblast proliferation and incorporate into a scar without producing a foreign body reaction. The use of porcine small intestine sub-mucosa plugs in the management of anal fistulas has been well documented and described, producing closure rates of 38-65%. We present a series of upper gastrointestinal fistula managed with endoscopic intervention and insertion of biological fistula plug over a 2 year period across 3 Hospitals, both public and private, in Western Australia and a video of the procedures will be presented.

Methods
Over a two-year period 13 patients were referred for treatment of acute or persistent foregut fistulas. All fistulas were managed with endoscopic intervention and insertion of a porcine small intestine sub-mucosa plug (Biodesign ® Cook medical inc, Bloomington, IN, USA). No patients with fistula were excluded. Data was collected on patient demographics and underlying diagnosis. The biological plugs were deployed using 2 different endoscopic techniques( deployment via the endoscope, or Pull through via a guide wire using a rendezvous technique ), both under a general anaesthetic.

RESULTS
Between January 2012 and April 2013 we treated 13 patients with foregut fistula using biological plugs. The age of the fistulas treated ranged from 14 days to 3 years. All fistulas were wither low or moderate output (<500mls/day). There were no high output fistulas managed during this period. The fistulas were predominantly gastric in origin (7 cases). 3 oesophageal, 1 bronchopleural and 2 jejunal fistulas were also managed using this technique. The aetiology of the fistulas varied, with 3 being persisting gastrostomy sites which had failed to close, 4 were anastamotic leaks which had fistulated, and 3 were enteric perforations, either iatrogenic (2) or due to traumatic injury (1).
Of the 13 fistulas treated using this method, 12 resolved following the treatment. Time to closure of the fistula varied from 1 day to 26 days (median 2 days). Proximal enteric feeding was commenced in 7 of the patients on the first postoperative day. In one patient the fistula was bronchopleural, and as such feeding was not an issue. In the failed procedure proximal feeding of the patient was never established. 2 patient required two applications of the plugs to complete closure.
Conclusion
Biological plugs offer a further option for management of the traditionally difficult foregut fistulas without major morbidity associate with other treatment modalities. It is limited to the ability to deploy the plug endoscopically.

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