Endoscopic modalities for upper gastrointestinal leaks, fistulae and perforations

Abstract

BackgroundEndotherapy techniques are a recent addition to the suite of non‐surgical and minimally invasive strategies to manage patients with perforations, leaks and fistulae. The emergency nature of these conditions and the heterogeneity of pathologies encountered create difficulties when trying to select appropriate tools in these complex situations. The purpose of this article is to review experience at a tertiary academic centre, describe the various endoscopic tools available and the situations where they can be considered for use.MethodsSingle‐centre series and review of the published literature.ResultsOf 64 patients, 57 were successfully treated using endoscopic therapy, with surgery used only to provide drainage and suture fully covered metal stents in place to prevent migration.DiscussionSelection of an appropriate endotherapy or stent for a patient with an oesophago‐gastric perforation or fistula requires an understanding of the anatomy and physiology underlying the patient's presentation and an understanding of the strengths and weaknesses of the available methods. Standard surgical principles of drainage, avoidance of distal obstruction and nutrition remain central to successful outcomes. A combination of surgical and endoscopic treatments may reduce the number of required treatments and can provide the ability to anchor fully covered stents to prevent them from migrating.

Endoscopic suturing as a less invasive approach for the treatment of anastomotic leakage after esophagogastrostomy – a case report

“…Conservative strategies are only reasonable for small leakages in patients with low clinical impact. In contrast, cases of large defects, severe sepsis, and bowel obstruction are rather managed surgically [7]. An endoscopic approach should be taken into consideration when an intervention is necessary and technically possible, and surgery should be avoided because of comorbidities, contraindications, or the patient's wish.…”

Successful management of perforated duodenal diverticulum by use of endoscopic drainage

“… 3 , 9 , 10 Several case reports have shown successful nonoperative treatment of patients' condition by use of bowel rest, intravenous antibiotics, and, in some cases, percutaneous drainage. 1 , 11 , 12 A recent report by Talbot et al 13 showed that minimally invasive endoscopic techniques for drainage of perforations, leaks, and fistulae are a successful strategy for the management of intraabdominal pathologic conditions that would otherwise require surgery. In their study, all of their patients had uncomplicated recoveries without recurrence of leaks, and they tolerated fluid diets after drain placement.…”

Endoscopic approach to anastomotic leaks: partially covered self-expandable stents. A single center’s experience

“…To prevent this event, clip application, large size of indwelling stent, suture fixation and partial covered stent usage have been shown to decrease the treatment failure rates [2,14,15].…”

“…Anal pain and migration related to the stent were a significant problem and were frequently encountered when the anastomosis was within 5 cm of the anal canal. Partially covered stents have proximal and distal mesh flares for [14]. On the other hand, this feature may result in impaction of the stent to the tissue wall by excessive fibrosis and granulation tissue leading to perforation or inability to remove the stent [24,25].…”