Endoscopic closure of an anastomo-cutaneous fistula: Filling and shielding using polyglycolic acid sheets and fibrin glue with easily deliverable technique

Abstract

Background and study aims Recently, endoscopic closure of gastrointestinal fistulas using polyglycolic acid (PGA) sheets with fibrin glue (FG) has been attempted. A 70-year-old woman who had undergone pancreaticoduodenectomy for pancreatic cancer suffered from a refractory anastomo-cutaneous fistula at the site of gastro-jejunostomy. We attempted endoscopic closure with filling and shielding using PGA sheets and FG. After introducing a guidewire into the fistula, a small piece of PGA sheet was skewered onto the guidewire and then pushed using a tapered catheter over the guidewire and delivered into the fistula. A total of 10 sheets were delivered via the same procedure. Next, the mucosa around the fistula was ablated, and the orifice of the fistula along with the surrounding mucosa was shielded with a piece of PGA sheet fixed with hemoclips and FG. After this procedure, the leakage disappeared and the fistula was undetectable on contrast radiograms. Endoscopic closure of anastomo-cutaneous fistula with filling and shielding using PGA sheets and FG is an effective, safe, low-invasive treatment, and the filling technique using a guidewire ensures a safe, smooth procedure.

Endoscopic management of tracheoesophageal fistulas

“…Combination therapy was a safe alternative to open surgical repair, as only three patients experienced respiratory distress syndrome and one patient required a tracheostomy [24]. Other studies support and recommend the use of fibrin glue in combination with abrasive therapy as providing the best outcomes [25,26]. Additionally, societies such as the American Society for Gastrointestinal Endoscopy report that fibrin glue provides endoscopists with ease of use without any risk of damage to the endoscope [27].…”

Filling of Polyglycolic Acid Sheets for Closure of Gastrointestinal Fistulas With an Easily Deliverable Technique Using a Guidewire

“…Recently, a number of approaches for the endoscopic management of GI leaks and fistulas, including clip closure, endoscopic suturing, stent placement and tissue sealants, have been developed, and the efficacy of such procedures has been reported [1,5]. As one endoscopic treatment with tissue sealants, endoscopic closure using polyglycolic acid (PGA) sheets with fibrin glue (FG) has been attempted due to the harmless nature of these sheets and the satisfactory results have been achieved in various surgical fields [6][7][8][9][10][11][12]. Nakano et al [13] evaluated the clinical efficacy of endoscopic plombage using PGA sheets and FG to close GI fistulas in 10 cases, and 70% of fistulas were successfully closed with one to four applications during the observation period (median duration 31 (range 0 -60) months).…”

“…Nakano et al [13] evaluated the clinical efficacy of endoscopic plombage using PGA sheets and FG to close GI fistulas in 10 cases, and 70% of fistulas were successfully closed with one to four applications during the observation period (median duration 31 (range 0 -60) months). In addition, concurrent additional techniques, including ablation with argon plasma coagulation (APC) and shielding of the orifice using a PGA sheet, were attempted to promote the fixation of filling PGA sheets [11][12][13][14]. However, various aspects, including suitable indications, methodology and the long-term effects of this procedure, have not been sufficiently investigated.…”

“…This procedure should be repeated several times in order to prevent mesh dislocation; however, it can be technically difficult to apply the sheets, and blindly inserting such pushing devices can injure the fistula. Therefore, we developed a technique to easily deliver PGA sheets with a guidewire and reported a case of GI fistula that was successfully treated with filling and shielding of PGA sheets and FG using this delivery technique [12].…”

Endoscopic shielding using oxidized regenerated cellulose after argon plasma coagulation under mandatory dual antiplatelet therapy

“…Endoscopic shielding following APC for angiodysplasia has not yet been reported and may represent a reasonable approach to increasing the safety of APC in DAPT patients, although this clinical assumption may warrant formal systematic study. Many reports on endoscopic shielding have implemented complex delivery approaches, particularly for coverage of extensive mucosal defects, for example, utilizing specialized catheters and standard additional fibrin glue (FG) spraying through specialized catheters with or without clipping, rendering the procedure potentially high‐cost, time‐consuming, and complex . However, in clinical situations with limited mucosal areas to be covered, the need for FG utilization may become questioned, and standard biopsy forceps delivery followed by clip fixation is considered a more straightforward and easy‐to‐implement approach for endoscopic shielding using oxidized regenerated cellulose in more circumscribed endoscopic situations.…”