Endoscopic management of gastrointestinal leaks and fistulae: What option do we have?

Abstract

Gastrointestinal leaks and fistulae are serious, potentially life threatening conditions that may occur with a wide variety of clinical presentations. Leaks are mostly related to post-operative anastomotic defects and are responsible for an important share of surgical morbidity and mortality. Chronic leaks and long standing post-operative collections may evolve in a fistula between two epithelialized structures. Endoscopy has earned a pivotal role in the management of gastrointestinal defects both as first line and as rescue treatment. Endotherapy is a minimally invasive, effective approach with lower morbidity and mortality compared to revisional surgery. Clips and luminal stents are the pioneer of gastrointestinal (GI) defect endotherapy, whereas innovative endoscopic closure devices and techniques, such as endoscopic internal drainage, suturing system and vacuum therapy, has broadened the indications of endoscopy for the management of GI wall defect. Although several endoscopic options are currently used, a standardized evidence-based algorithm for management of GI defect is not available. Successful management of gastrointestinal leaks and fistulae requires a tailored and multidisciplinary approach based on clinical presentation, defect features (size, location and onset time), local expertise and the availability of devices. In this review, we analyze different endoscopic approaches, which we selected on the basis of the available literature and our own experience. Then, we evaluate the overall efficacy and procedural-specific strengths and weaknesses of each approach.

Outcomes of gastrointestinal fistulas: Results from a multi-continent, multi-national, multi-center cohort

“…GIF was established after output of intestinal liquor through an orifice in the abdominal wall and/or the exposure of the intestinal mucosae to the exterior. [1][2][3][4][5][6] Exclusion criteria: Patients with fistulas of the biliary tree and the pancreatic duct were excluded.…”

“…Gastrointestinal fistulas (GIF) represent a serious complication of the surgical processes, and bear a high risk of hydroelectrolyte disorders, sepsis, malnutrition and death. [1][2] Hence, with repercussions of GIF known, timely recognition, accurate diagnosis (integrating criteria on the spontaneous closure-also read as conservative | non-surgical-of the GIF); and adoption of the required measures for hydroelectrolyte repletion, nutritional support and containment of sepsis are imperative for a better prognosis of GIF.…”

“…Incidence of GIF is estimated to vary between 4 -20 % of the operated patients, [1][2] but this estimate might vary with the typology of the health institution, and the volume and complexity of the surgeries completed in a year. Almost half of the GIF originate in patients in whom no intestinal anastomosis is performed, but suffer inadvertent enterectomies during the surgical act.…”

Endoscopic Management of Enterocutaneous Fistulae

“…TTS clips that pass through the endoscope working channel are widely available therapeutic devices that have been used to close GI defects for decades. [19][20][21][22] Most TTS clips are compatible with standard upper endoscopes and colonoscopes and their application requires minimal therapeutic endoscopic skill. Additionally, because they pass through the working channel of the endoscope, one does not need to remove the endoscope to affix a closure device to the distal tip of the endoscope (and subsequently readvance to the area of the ECF).…”

Terapia endoscópica de presión negativa para cierre de fístula esófago-yeyunal. Reporte de caso

“…Dependiendo de la magnitud de la fístula y el estado clínico del paciente, dentro de las actuales alternativas de manejo existen opciones conservadoras que incluyen nutrición parenteral o enteral distal a la fuga, drenaje abdominal y cubrimiento antibiótico, hasta técnicas mínimamente invasivas como o el manejo endoscópico con o sin drenaje o invasivas como la re-intervención quirúrgica (8,9). Durante la última década, los enfoques no quirúrgicos han tenido un mayor impacto en el tratamiento de defectos gastrointestinales superiores.…”