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Dovbenko O, Herasymenko O. Endoscopic management of hepaticojejunal anastomosis fistula after Whipple's resection. Endoscopy 2024; 56:E72-E73. [PMID: 38262462 PMCID: PMC10805614 DOI: 10.1055/a-2226-0276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Affiliation(s)
- Oleg Dovbenko
- Department of Endoscopic Surgery, Military Medical Clinical Centre, Odesa, Ukraine
| | - Oleg Herasymenko
- Department of Endoscopic Surgery, Military Medical Clinical Centre, Odesa, Ukraine
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2
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Adekolu AA, Cohen EM, Shah-Khan SM, Maan S, Foryoung J, Ajibade A, Thakkar S, Singh S. Endoscopic closure of a recto-pelvic fistula with a cardiac septal occluder device. VIDEOGIE : AN OFFICIAL VIDEO JOURNAL OF THE AMERICAN SOCIETY FOR GASTROINTESTINAL ENDOSCOPY 2024; 9:31-34. [PMID: 38261842 PMCID: PMC10793229 DOI: 10.1016/j.vgie.2023.09.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Abstract
Video 1Endoscopic closure of a recto-pelvic fistula with a cardiac septal occluder device in a patient for whom other surgical and endoscopic interventions had failed.
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Affiliation(s)
- Ayowumi A Adekolu
- Section of Internal Medicine, West Virginia University, Morgantown, West Virginia
| | - Ethan M Cohen
- Section of Internal Medicine, West Virginia University, Morgantown, West Virginia
| | - Sardar Momin Shah-Khan
- Section of Gastroenterology and Hepatology, West Virginia University, Morgantown, West Virginia
| | - Soban Maan
- Section of Gastroenterology and Hepatology, West Virginia University, Morgantown, West Virginia
| | - Joyce Foryoung
- Section of Internal Medicine, West Virginia University, Morgantown, West Virginia
| | - Ademola Ajibade
- Section of Internal Medicine, West Virginia University, Morgantown, West Virginia
| | - Shyam Thakkar
- Section of Gastroenterology and Hepatology, West Virginia University, Morgantown, West Virginia
| | - Shailendra Singh
- Section of Gastroenterology and Hepatology, West Virginia University, Morgantown, West Virginia
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3
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Medas R, Rodrigues-Pinto E. Endoscopic treatment of upper gastrointestinal postsurgical leaks: a narrative review. Clin Endosc 2023; 56:693-705. [PMID: 37430398 PMCID: PMC10665610 DOI: 10.5946/ce.2023.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 03/28/2023] [Accepted: 04/01/2023] [Indexed: 07/12/2023] Open
Abstract
Upper gastrointestinal postsurgical leaks are life-threatening conditions with high mortality rates and are one of the most feared complications of surgery. Leaks are challenging to manage and often require radiological, endoscopic, or surgical intervention. Steady advancements in interventional endoscopy in recent decades have allowed the development of new endoscopic devices and techniques that provide a more effective and minimally invasive therapeutic option compared to surgery. Since there is no consensus regarding the most appropriate therapeutic approach for managing postsurgical leaks, this review aimed to summarize the best available current data. Our discussion specifically focuses on leak diagnosis, treatment aims, comparative endoscopic technique outcomes, and combined multimodality approach efficacy.
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Affiliation(s)
- Renato Medas
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Eduardo Rodrigues-Pinto
- Gastroenterology Department, Centro Hospitalar São João, Porto, Portugal
- Faculty of Medicine of the University of Porto, Porto, Portugal
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4
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Drefs M, Schardey J, von Ehrlich-Treuenstätt V, Wirth U, Burian M, Zimmermann P, Werner J, Kühn F. Endoscopic Treatment Options for Gastrointestinal Leaks. Visc Med 2022; 38:311-321. [PMID: 37970585 PMCID: PMC10642546 DOI: 10.1159/000526759] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 08/19/2022] [Indexed: 11/17/2023] Open
Abstract
Background Spontaneous or postoperative gastrointestinal defects are still life-threatening complications with elevated morbidity and mortality. Recently, endoscopic treatment options - up and foremost endoscopic vacuum therapy (EVT) - have become increasingly popular and have shown promising results in these patients. Methods We performed an electronic systematic search of the MEDLINE databases (PubMed, EMBASE, and Cochrane) and searched for studies evaluating endoscopic options for the treatment of esophageal and colorectal leakages and/or perforations until March 2022. Results The closure rate of both esophageal and colorectal defects by EVT is high and even exceeds the results of surgical revision in parts. Out of all endoscopic treatment options, EVT shows most evidence and appears to have the highest therapeutic success rates. Furthermore, EVT for both indications had a low rate of serious complications without relevant in-hospital mortality. In selected patients, EVT can be applied without fecal diversion and transferred to an outpatient setting. Conclusion Despite multiple endoscopic treatment options, EVT is increasingly becoming the new gold standard in endoscopic treatment of extraperitoneal defects of the upper and lower GI tract with localized peritonitis or mediastinitis and without close proximity to major blood vessels. However, further prospective, comparative studies are needed to strengthen the current evidence.
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Affiliation(s)
- Moritz Drefs
- Department of General, Visceral and Transplant Surgery, University Hospital of Munich, Munich, Germany
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5
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Persaud T, Dawod E, Shah S, Sharaiha R, Sampath K. Endoscopic management of gastrojejunocolic fistula after endoscopic gastrojejunostomy. VideoGIE 2022; 7:395-397. [DOI: 10.1016/j.vgie.2022.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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6
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Galloro G, Zullo A, Luglio G, Chini A, Telesca DA, Maione R, Pollastro M, De Palma GD, Manta R. Endoscopic clipping in non-variceal upper gastrointestinal bleeding treatment. Clin Endosc 2022; 55:339-346. [PMID: 35534934 PMCID: PMC9178136 DOI: 10.5946/ce.2021.249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 01/05/2022] [Indexed: 11/20/2022] Open
Abstract
Since the earliest reports, advanced clipping systems have been developed, and it is possible to choose among many models with different structural and technical features. The main drawback of through-the-scope clips is their small size, which allows the compression of limited amounts of tissue needed for large-size vessel treatment. Therefore, the over-the-scope clip system was realized, allowing a larger and stronger mechanical compression of large tissue areas, with excellent results in achieving a definitive hemostasis in difficult cases. Many studies have analyzed the indications and efficacy of two-pronged endoclips and have shown good results for initial and permanent hemostasis. The aim of this review was to provide updated information on indications, positioning techniques, and results of clip application for endoscopic treatment of upper gastrointestinal non-variceal bleeding lesions.
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Affiliation(s)
- Giuseppe Galloro
- Surgical Endoscopy Unit, Department of Clinical Medicine and Surgery, Federico II University of Naples, Napoli, Italy
- Correspondence to: Giuseppe Galloro Department of Clinical Medicine and Surgery, Federico II University of Naples, Via Sergio Pansini, 5, Naples 80131, Italy E-mail:
| | - Angelo Zullo
- Gastroenterology and Digestive Endoscopy Unit, Nuovo Regina Margherita Hospital, Roma, Italy
| | - Gaetano Luglio
- Surgical Endoscopy Unit, Department of Clinical Medicine and Surgery, Federico II University of Naples, Napoli, Italy
| | - Alessia Chini
- Surgical Endoscopy Unit, Department of Clinical Medicine and Surgery, Federico II University of Naples, Napoli, Italy
| | | | - Rosa Maione
- Surgical Endoscopy Unit, Department of Clinical Medicine and Surgery, Federico II University of Naples, Napoli, Italy
| | - Matteo Pollastro
- Surgical Endoscopy Unit, Department of Clinical Medicine and Surgery, Federico II University of Naples, Napoli, Italy
| | - Giovanni Domenico De Palma
- Surgical Endoscopy Unit, Department of Clinical Medicine and Surgery, Federico II University of Naples, Napoli, Italy
| | - Raffaele Manta
- Gastroenterology and Digestive Endoscopy Unit, General Hospital, Perugia, Italy
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7
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Leeds IL, Sklow B. Through the Looking Glass: Endoscopic management of anastomotic leaks. SEMINARS IN COLON AND RECTAL SURGERY 2022. [DOI: 10.1016/j.scrs.2022.100885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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8
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Endoscopic vacuum therapy for the treatment of colorectal leaks - a systematic review and meta-analysis. Int J Colorectal Dis 2022; 37:283-292. [PMID: 34817647 PMCID: PMC8803669 DOI: 10.1007/s00384-021-04066-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/09/2021] [Indexed: 02/04/2023]
Abstract
BACKGROUND During the last two decades, vacuum-assisted wound therapy has been successfully transferred to an endoscopic treatment approach of various upper and lower gastrointestinal leaks called endoscopic vacuum therapy (EVT). As mostly small case series are published in this field, the aim of our systematic review and meta-analysis was to evaluate the efficacy and safety of EVT in the treatment of colorectal leaks. METHODS A systematic search of MEDLINE/PubMed and Cochrane databases was performed using search terms related to EVT and colorectal defects (anastomotic leakage, rectal stump insufficiency) according to the PRISMA guidelines. Randomized controlled trials (RCTs), observational studies, and case series published by December 2020 were eligible for inclusion. A meta-analysis was conducted on the success of EVT, stoma reversal rate after EVT as well as procedure-related complications. Statistical interferences were based on pooled estimates from random effects models using DerSimonian-Laird estimator. RESULTS Only data from observational studies and case series were available. Twenty-four studies reporting on 690 patients with colorectal defects undergoing EVT were included. The mean rate of success was 81.4% (95% CI: 74.0%-87.1%). The proportion of diverted patients was 76.4% (95% CI: 64.9%-85.0%). The mean rate of ostomy reversal across the studies was 66.7% (95% CI: 58.0%-74.4%). Sixty-four patients were reported with EVT-associated complications, the weighted mean complication rate across the studies was 12.1% (95% CI: 9.7%-15.2%). CONCLUSIONS Current medical evidence on EVT in patients with colorectal leaks lacks high quality data from RCTs. Based on the data available, EVT can be seen as a feasible treatment option with manageable risks for selected patients with colorectal leaks.
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9
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Wang Q, Li J, Liu S, Fang C, Chen W. Efficacy and safety of over-the-scope clips for colorectal leaks and fistulas: a pooled analysis. MINIM INVASIV THER 2021; 31:825-834. [PMID: 34871538 DOI: 10.1080/13645706.2021.2010218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The development of laparoscopic technologies and continuous improvements in intracavitary anastomosis technology have significantly reduced the incidence of anastomotic leak (AL) following colorectal surgery. However, AL incidence can significantly increase the duration of patient hospitalization, patient medical expenses, and incidence of mortality. The recently developed over-the-scope clip (OTSC) system has been of increasing clinical interest owing to its ease of use, low complication rates, and high rates of technical and clinical success. The PubMed/Medline, EMBASE, and Cochrane PubMed Library were systematically searched for all studies of OTSC system-mediated closure of ALs and fistulas published from January 2010 to January 2021. Two reviewers independently identified relevant studies based on appropriate inclusion and exclusion criteria. A total of nine studies were included in the present analysis, incorporating 114 patients of whom 107 were treated with an OTSC system. The technical success rate for these patients was 84% (95%CI, 73.5-94.5%; I2 53%), and the clinical success rate was 74.3% (95%CI, 64.4-84.1%; I2 28%) as calculated via a pooled proportion analysis. Complications occurred in two patients. The endoscopic OTSC system is a safe and effective means of treating ALs and fistulas after colorectal surgery.
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Affiliation(s)
- Qianyu Wang
- The Second Clinical Medical College of Shanxi Medical University, Taiyuan, China
| | - Jie Li
- The Second Clinical Medical College of Shanxi Medical University, Taiyuan, China
| | - Shuang Liu
- The Second Clinical Medical College of Shanxi Medical University, Taiyuan, China
| | - Changzhong Fang
- The Second Clinical Medical College of Shanxi Medical University, Taiyuan, China
| | - Wenliang Chen
- Department of General Surgery, The 2nd Affiliated Hospital of Shanxi Medical University, Taiyuan, China
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10
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Liesenfeld LF, Schmidt T, Zhang-Hagenlocher C, Sauer P, Diener MK, Müller-Stich BP, Hackert T, Büchler MW, Schaible A. Self-expanding Metal Stents for Anastomotic Leaks After Upper Gastrointestinal Cancer Surgery. J Surg Res 2021; 267:516-526. [PMID: 34256194 DOI: 10.1016/j.jss.2021.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 04/25/2021] [Accepted: 06/08/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Anastomotic leakage (AL) is a common and severe complication after upper gastrointestinal (UGI) surgery. Although evidence is scarce, endoscopic deployed self-expanding metal stents (SEMS) are well-established for the management of AL in UGI surgery. The present study aimed to evaluate the feasibility, effectiveness, and safety of SEMS in terms of success, mortality, and morbidity in patients with AL after UGI cancer surgery. MATERIALS AND METHODS Patients with AL after primary UGI cancer surgery were retrospectively analyzed with regard to demographics, disease, surgical and endoscopic procedures, and complications. Stent treatment success was divided into technical, primary (within 72 hours of stent deployment), sustained (after 72 hours of stent deployment), and sealing success. RESULTS In a total of 63 patients, 74 stents were used and 11 were deployed in endoscopic reinterventions. Stent deployment was successful in all patients. Primary and sustained success rates were 68.3% (n = 43) and 65.1% (n = 41), respectively. Of the primarily successfully treated patients, 87.8% remained successfully treated. If primary treatment was unsuccessful, it remained unsuccessful in 66.6% of the patients (P = 0.002). Final sealing of the leakage was observed in 65.1% of patients (n = 41). Longer stent shafts and wider stent end widths were correlated with successful stent treatment (P < 0.05). CONCLUSION SEMS are a safe and sufficient tool in the treatment of AL after UGI cancer surgery. Treatment success is improved with longer stent shafts and wider stent end widths. Switching to alternative treatments is strongly suggested if signs of persistent leakage are present beyond 72 hours after stent placement, as this is highly indicative of sustained stent failure.
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Affiliation(s)
- Lukas F Liesenfeld
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany.
| | - Thomas Schmidt
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Peter Sauer
- Department of Gastroenterology, University Hospital Heidelberg, Heidelberg, Germany
| | - Markus K Diener
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Beat P Müller-Stich
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Thilo Hackert
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Markus W Büchler
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Anja Schaible
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
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11
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Retrospective multicenter study on endoscopic treatment of upper GI postsurgical leaks. Gastrointest Endosc 2021; 93:1283-1299.e2. [PMID: 33075368 DOI: 10.1016/j.gie.2020.10.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 10/09/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Therapeutic endoscopy plays a critical role in the management of upper GI (UGI) postsurgical leaks. Data are scarce regarding clinical success and safety. Our aim was to evaluate the effectiveness of endoscopic therapy for UGI postsurgical leaks and associated adverse events (AEs) and to identify factors associated with successful endoscopic therapy and AE occurrence. METHODS This was a retrospective, multicenter, international study of all patients who underwent endoscopic therapy for UGI postsurgical leaks between 2014 and 2019. RESULTS Two hundred six patients were included. Index surgery most often performed was sleeve gastrectomy (39.3%), followed by gastrectomy (23.8%) and esophagectomy (22.8%). The median time between index surgery and commencement of endoscopic therapy was 16 days. Endoscopic closure was achieved in 80.1% of patients after a median follow-up of 52 days (interquartile range, 33-81.3). Seven hundred seventy-five therapeutic endoscopies were performed. Multimodal therapy was needed in 40.8% of patients. The cumulative success of leak resolution reached a plateau between the third and fourth techniques (approximately 70%-80%); this was achieved after 125 days of endoscopic therapy. Smaller leak initial diameters, hospitalization in a general ward, hemodynamic stability, absence of respiratory failure, previous gastrectomy, fewer numbers of therapeutic endoscopies performed, shorter length of stay, and shorter times to leak closure were associated with better outcomes. Overall, 102 endoscopic therapy-related AEs occurred in 81 patients (39.3%), with most managed conservatively or endoscopically. Leak-related mortality rate was 12.4%. CONCLUSIONS Multimodal therapeutic endoscopy, despite being time-consuming and requiring multiple procedures, allows leak closure in a significant proportion of patients with a low rate of severe AEs.
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12
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Sharp G, Steffens D, Koh CE. Evidence of negative pressure therapy for anastomotic leak: a systematic review. ANZ J Surg 2021; 91:537-545. [PMID: 33480168 DOI: 10.1111/ans.16581] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2020] [Revised: 11/09/2020] [Accepted: 11/16/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Anastomotic leak (AL) is a devastating complication. Several new treatment options are available, endoluminal negative pressure therapy is one. The aims of this systematic review are; to report success rates and stoma closure rates following endoluminal negative pressure therapy in colorectal AL patients. METHODS A systematic review of MEDLINE, PubMed, Cochrane and Embase databases from inception to June 2018. Search limits were; English language, humans, sample >5 and >18 years. Search terms were Endospong* OR Endo-spong* OR Endo spong* OR Endoluminal negative pressure OR Endoluninal vac* OR Vacuum assisted OR negative pressure. Combined with colon OR rectum OR colorect* AND anastomotic leak OR leak*. RESULTS Twenty articles met inclusion criteria. There were 334 patients. Reported success rates ranged from 60% to 100%. However, success definition varied considerably. The most widely used definition was endoscopic assessment of residual cavity size, but this also varied from 0.5 cm to 3 cm. Stoma closure rates were only reported in 11 studies and ranged from 31% to 100%. Complication rates were reported in 13 studies (65%). The most common was on-going sepsis. CONCLUSIONS Included studies suggest that 60-100% of ALs heal with endoluminal negative pressure therapy. However, results from this review need to be interpreted with caution because of the variable definition of success. A more objective assessment of success may be stoma closure but this is only reported in 60% of studies. Further studies are needed to assess the benefit of negative pressure therapy in anastomotic leaks.
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Affiliation(s)
- Gary Sharp
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Daniel Steffens
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Cherry E Koh
- Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,RPA Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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13
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Morrell DJ, McKenna KJ, Messaris E, Pauli EM. Endoscopic management of recurrent anastomotic leak following chemotherapy after colorectal surgery - a video vignette. Colorectal Dis 2020; 22:1451-1452. [PMID: 32281713 DOI: 10.1111/codi.15072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 03/25/2020] [Indexed: 02/08/2023]
Affiliation(s)
- D J Morrell
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - K J McKenna
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - E Messaris
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - E M Pauli
- Department of Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
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14
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Bartell N, Bittner K, Kaul V, Kothari TH, Kothari S. Clinical efficacy of the over-the-scope clip device: A systematic review. World J Gastroenterol 2020; 26:3495-3516. [PMID: 32655272 PMCID: PMC7327783 DOI: 10.3748/wjg.v26.i24.3495] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 05/19/2020] [Accepted: 05/29/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The over-the-scope clip (OTSC) system has been increasingly utilized as a non-surgical option to endoscopically manage refractory gastrointestinal (GI) hemorrhage, perforations/luminal defects and fistulas. Limited data exist evaluating the efficacy and safety of OTSC.
AIM To determine the clinical success and adverse event (AE) rates of OTSC across all GI indications.
METHODS A PubMed search was conducted for eligible articles describing the application of the OTSC system for any indication in the GI tract. Any article or case series reporting data for less than 5 total patients was excluded. The primary outcome was the rate of clinical success. Secondary outcomes included: Technical success rate, OTSC-related AE rate and requirement for surgical intervention despite-OTSC placement. Pooled rates (per-indication and overall) were calculated as the number of patients with the event of interest divided by the total number of patients.
RESULTS A total of 85 articles met our inclusion criteria (n = 3025 patients). OTSC was successfully deployed in 94.4% of patients (n = 2856/3025). The overall rate of clinical success (all indications) was 78.4% (n = 2371/3025). Per-indication clinical success rates were as follows: (1) 86.0% (1120/1303) for GI hemorrhage; (2) 85.3% (399/468) for perforation; (3) 55.8% (347/622) for fistulae; (4) 72.6% (284/391) for anastomotic leaks; (5) 92.8% (205/221) for defect closure following endoscopic resection (e.g., following endoscopic mucosal resection or endoscopic submucosal dissection); and (6) 80.0% (16/20) for stent fixation. AE’s related to the deployment of OTSC were only reported in 64 of 85 studies (n = 1942 patients), with an overall AE rate of 2.1% (n = 40/1942). Salvage surgical intervention was required in 4.7% of patients (n = 143/3025).
CONCLUSION This systematic review demonstrates that the OTSC system is a safe and effective endoscopic therapy to manage GI hemorrhage, perforations, anastomotic leaks, defects created by endoscopic resections and for stent fixation. Clinical success in fistula management appears limited. Further studies, including randomized controlled trials comparing OTSC with conventional and/or surgical therapies, are needed to determine which indication(s) are the most effective for its use.
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Affiliation(s)
- Nicholas Bartell
- Division of Gastroenterology and Hepatology, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - Krystle Bittner
- Division of Gastroenterology and Hepatology, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - Vivek Kaul
- Division of Gastroenterology and Hepatology, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - Truptesh H Kothari
- Division of Gastroenterology and Hepatology, University of Rochester Medical Center, Rochester, NY 14642, United States
| | - Shivangi Kothari
- Division of Gastroenterology and Hepatology, University of Rochester Medical Center, Rochester, NY 14642, United States
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15
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Al-Asiry J, Lord R, Mohammed N. Management of spontaneous and iatrogenic perforations, leaks and fistulae of the upper gastrointestinal tract. Ther Adv Gastrointest Endosc 2020; 12:2631774519895845. [PMID: 31909396 PMCID: PMC6935768 DOI: 10.1177/2631774519895845] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Accepted: 11/27/2019] [Indexed: 12/21/2022] Open
Abstract
Upper gastrointestinal perforations, leaks and fistulae are relatively common occurrences with a growing number of these complications occuring as a result of therapeutic advancement and adoption of newer and bolder endoscopic therapies. Historically, these were predominantly managed surgically; however, owing to high morbidity and mortality associated with surgical repair, endoscopic options are preferable. Over the past decade, vast expansion in the endoscopic armamentarium for the management of perforations, leaks and fistulae has led to endoscopic management now being the first-line treatment. Here, we will review the endoscopic modalities including through-the-scope clips, over-the-scope clips, stents, vacuum therapy, endoscopic sutures and sealants. In addition, we will discuss nonendoscopic approach to management including early recognition of perforations, ways to reduce septic complications and format algorithms to guide therapy for different scenarios. However, it is important to stress that there is a lack of high-quality randomised studies to clearly guide management of such complications, resulting in a wide variation of approaches in management by specialists. Each case requires some degree of individualisation due to the potential array of problems encountered and patient-specific co-morbidities. In the future, more robust studies are clearly required to better guide specialist management.
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Affiliation(s)
- Jamal Al-Asiry
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Richard Lord
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Noor Mohammed
- Department of Gastroenterology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
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16
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de Moura DTH, de Moura BFBH, Manfredi MA, Hathorn KE, Bazarbashi AN, Ribeiro IB, de Moura EGH, Thompson CC. Role of endoscopic vacuum therapy in the management of gastrointestinal transmural defects. World J Gastrointest Endosc 2019; 11:329-344. [PMID: 31205594 PMCID: PMC6556487 DOI: 10.4253/wjge.v11.i5.329] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 04/16/2019] [Accepted: 05/01/2019] [Indexed: 02/06/2023] Open
Abstract
A gastrointestinal (GI) transmural defect is defined as total rupture of the GI wall, and these defects can be divided into three categories: perforations, leaks, and fistulas. Surgical management of these defects is usually challenging and may be associated with high morbidity and mortality rates. Recently, several novel endoscopic techniques have been developed, and endoscopy has become a first-line approach for therapy of these conditions. The use of endoscopic vacuum therapy (EVT) is increasing with favorable results. This technique involves endoscopic placement of a sponge connected to a nasogastric tube into the defect cavity or lumen. This promotes healing via five mechanisms, including macrodeformation, microdeformation, changes in perfusion, exudate control, and bacterial clearance, which is similar to the mechanisms in which skin wounds are treated with commonly employed wound vacuums. EVT can be used in the upper GI tract, small bowel, biliopancreatic regions, and lower GI tract, with variable success rates and a satisfactory safety profile. In this article, we review and discuss the mechanism of action, materials, techniques, efficacy, and safety of EVT in the management of patients with GI transmural defects.
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Affiliation(s)
- Diogo Turiani Hourneaux de Moura
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital - Harvard Medical School, Boston, MA 02115, United States
- Department of Endoscopy of Clinics Hospital of São Paulo University, São Paulo 05403-000, Brazil
| | | | - Michael A Manfredi
- Esophageal and Airway Atresia Treatment Center, Boston Children's Hospital - Harvard Medical School, Boston, MA 02115, United States
| | - Kelly E Hathorn
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital - Harvard Medical School, Boston, MA 02115, United States
| | - Ahmad N Bazarbashi
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital - Harvard Medical School, Boston, MA 02115, United States
| | - Igor Braga Ribeiro
- Department of Endoscopy of Clinics Hospital of São Paulo University, São Paulo 05403-000, Brazil
| | | | - Christopher C Thompson
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women’s Hospital - Harvard Medical School, Boston, MA 02115, United States
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Weiland T, Rohrer S, Schmidt A, Wedi E, Bauerfeind P, Caca K, Khashab MA, Hochberger J, Baur F, Gottwald T, Schurr MO. Efficacy of the OTSC System in the treatment of GI bleeding and wall defects: a PMCF meta-analysis. MINIM INVASIV THER 2019; 29:121-139. [PMID: 30957599 DOI: 10.1080/13645706.2019.1590418] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Since its market launch in 2007, the endoscopic OTSC clipping system has been the object of intensive clinical research. These data were systematically collected for post-market clinical follow-up (PMCF). The aim of the study was the systematic review of the efficacy and safety of the OTSC System. The PMCF database was systematically searched for clinical data on OTSC therapy of GI hemorrhage (H), acute leaks/perforations (AL) and chronic leaks/fistulae (CL). Major outcomes were successful clip application and durable hemostasis/closure of defects. Comprehensive pooled success proportions were established by meta-analytical methods. Four-hundred-fifty-seven publications were reviewed. Fifty-eight articles comprising 1868 patients fulfilled criteria to be included in the analysis. These consisted of retrospective analyses, prospective observational trials, one randomized-controlled trial (STING) and one quasi-controlled study (FLETRock). The pooled proportion analysis revealed high overall proportions of technical success: H - mean 93.0% [95%CI 90.2-95.4], AL-mean 89.7% [95%CI 85.9-92.9] and CL-mean 83.8% [95%CI 76.9-89.7]. Pooled durable clinical success proportions were: H-mean 87.5% [95%CI 80.5-93.2], AL-mean 81.4% [95%CI 77.0-85.3] and CL-mean 63.0% [95%CI 53.0-72.3]. By pooling all clinical data gained, we conclude that OTSC application in GI hemorrhage and closure of GI lesions is safe and effective in real clinical use.
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Affiliation(s)
| | | | - Arthur Schmidt
- Faculty of Medicine, Department of Medicine II, Medical Center, University of Freiburg, Freiburg, Germany.,Department of Gastroenterology and Oncology, Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Edris Wedi
- Department of Gastroenterology and Gastrointestinal Oncology, University Medical Centre Goettingen, Goettingen, Germany
| | - Peter Bauerfeind
- Department of Gastroenterology and Hepatology, Triemli Hospital, Zurich, Switzerland
| | - Karel Caca
- Department of Gastroenterology and Oncology, Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Mouen A Khashab
- Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, MA, USA
| | - Juergen Hochberger
- Department of Gastroenterology, Vivantes Klinikum in Friedrichshain, Berlin, Germany
| | | | - Thomas Gottwald
- Ovesco Endoscopy AG, Tuebingen, Germany.,Medical Faculty, Eberhard Karls University, Tuebingen, Germany
| | - Marc O Schurr
- Ovesco Endoscopy AG, Tuebingen, Germany.,Steinbeis University, Berlin, IHCI-Institute, Tuebingen, Germany
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18
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Efficacy of endoscopic vacuum therapy for the treatment of colorectal anastomotic leaks. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2019. [DOI: 10.1016/j.tgie.2019.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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19
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Early anastomotic complications in colorectal surgery: a systematic review of techniques for endoscopic salvage. Surg Endosc 2019; 33:1049-1065. [PMID: 30675662 PMCID: PMC6430759 DOI: 10.1007/s00464-019-06670-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 01/17/2019] [Indexed: 12/12/2022]
Abstract
Background Anastomotic complications following colorectal surgery are associated with significant morbidity and mortality. For patients in whom systemic sepsis is absent or well controlled, minimal access techniques, such as endoscopic therapies, are being increasingly employed to reduce the morbidity of surgical re-intervention. In this review, we aim to assess the utility of endoscopic management in the acute setting of colorectal anastomotic complications, focusing on anastomotic leak. Method A literature search was performed for published full text articles using the PubMed, Cochrane and Scopus databases using the search criteria string “colorectal anastomotic (“leak” OR “bleed”), “endoscopy”, endoscopic management”. Additional papers were detected by scanning the references of relevant papers. Data were extracted from each study by two authors onto a dedicated pro-forma. Given the nature of the data extracted, no meta-analysis was performed. Results A total of 89 papers were identified, 16 of which were included in this review; an additional 14 papers were obtained from reference searches. In patients who are not physiologically compromised, there are promising data regarding the salvage rate of stents, over-the-scope endoscopic clips, vacuum therapy and fibrin glue in the early management of colorectal anastomotic leak. There is no consensus regarding the optimal approach, and data to assist the physician in patient selection are lacking. Whilst data on salvage (i.e. healing and avoidance of surgery) are well understood, no data on functional outcomes are reported. Conclusion Endoscopic therapy in the management of stable patients with colorectal anastomotic leaks appears safe and in selected patients is associated with high rates of technical success. Challenges remain in selecting the most appropriate strategy, patient selection, and understanding the functional and long-term sequelae of this approach. Further evidence from large prospective cohort studies are needed to further evaluate the role of these novel strategies.
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Kobara H, Mori H, Nishiyama N, Fujihara S, Okano K, Suzuki Y, Masaki T. Over-the-scope clip system: A review of 1517 cases over 9 years. J Gastroenterol Hepatol 2019; 34:22-30. [PMID: 30069935 DOI: 10.1111/jgh.14402] [Citation(s) in RCA: 110] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 07/12/2018] [Accepted: 07/24/2018] [Indexed: 12/13/2022]
Abstract
Rescue therapy for gastrointestinal (GI) refractory bleeding, perforation, and fistula has traditionally required surgical interventions owing to the limited performance of conventional endoscopic instruments and techniques. An innovative clipping system, the over-the-scope clip (OTSC), may play an important role in rescue therapy. This innovative device is proposed as the final option in endoscopic treatment. The device presents several advantages including having a powerful sewing force for closure of GI defects using a simple mechanism and also having an innovative feature, whereby a large defect and fistula can be sealed using accessory forceps. Consequently, it is able to provide outstanding clinical effects for rescue therapy. This review clarifies the current status and limitations of OTSC according to different indications of GI refractory disease, including refractory bleeding, perforation, fistula, and anastomotic dehiscence. An extensive literature search identified studies reported 10 or more cases in which the OTSC system was applied. A total of 1517 cases described in 30 articles between 2010 and 2018 were retrieved. The clinical success rates and complications were calculated overall and for each indication. The average clinical success rate was 78% (n = 1517) overall, 85% for bleeding (n = 559), 85% (n = 351) for perforation, 52% (n = 388) for fistula, 66% (n = 97) for anastomotic dehiscence, and 95% (n = 122) for other conditions, respectively. The overall and severe OTSC-associated complications were 1.7% (n = 23) and 0.59% (n = 9), respectively. This review concludes that the OTSC system may serve as a safe and productive device for GI refractory diseases, albeit with limited success for fistula.
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Affiliation(s)
- Hideki Kobara
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Takamatsu, Japan
| | - Hirohito Mori
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Takamatsu, Japan
| | - Noriko Nishiyama
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Takamatsu, Japan
| | - Shintaro Fujihara
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Takamatsu, Japan
| | - Keiichi Okano
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Takamatsu, Japan
| | - Yasuyuki Suzuki
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, Takamatsu, Japan
| | - Tsutomu Masaki
- Department of Gastroenterology and Neurology, Faculty of Medicine, Kagawa University, Takamatsu, Japan
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Manta R, Mangiafico S, Zullo A, Bertani H, Caruso A, Grande G, Zito FP, Mangiavillano B, Pasquale L, Parodi A, Germanà B, Bassotti G, Monica F, Zilli M, Pisani A, Mutignani M, Conigliaro R, Galloro G. First-line endoscopic treatment with over-the-scope clips in patients with either upper or lower gastrointestinal bleeding: a multicenter study. Endosc Int Open 2018; 6:E1317-E1321. [PMID: 30410951 PMCID: PMC6221819 DOI: 10.1055/a-0746-8435] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 08/06/2018] [Indexed: 02/07/2023] Open
Abstract
Background and study aims Endoscopic treatment is the mainstay approach for gastrointestinal bleeding, in either upper (UGIB) or lower (LGIB) tract. The over-the-scope clip (OTSC) may overcome limitations of standard clips or thermocoagulation in high-risk bleeding lesions. We evaluate the main clinically relevant outcomes following endoscopic hemostasis with OTSC in high-risk lesions and/or patients. Patients and methods This was a retrospective analysis of prospectively collected databases including all patients with UGIB and LGIB who underwent OTCS placement as first-line treatment in eleven tertiary endoscopic referral centers. Technical success, primary hemostasis, rebleeding, blood transfusion, hospital stay, and hemorrhage-related mortality rates were evaluated. Results Data from 286 patients, with either UGIB (N = 214) or LGIB (N = 72) were available. Overall, 112 patients (39.2 %) were receiving antithrombotic therapy. Technical success and primary hemostasis rates were 97.9 % and 96.4 %, respectively. Early rebleeding occurred in 4.4 %, more frequently in those on antithrombotic therapy, and no late rebleeding was observed. Following a successful primary haemostasis, only 5.2 % patients needed blood transfusions, and the median hospital stay was 4 days (range: 3 - 11). Eighteen patients with either technical failure (N = 6) or rebleeding (N = 12) underwent radiological or surgical approaches. Overall, bleeding-related deaths occurred in 5 (1.7 %) patients, including 3 patients with technical procedural failure, and 2 in the rebleeding group. Conclusions Data from our large, multicenter study show that OTSC placement is an effective first-line treatment for hemostasis in high-risk patients and/or lesions both in upper and lower gastrointestinal tract.
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Affiliation(s)
- Raffaele Manta
- Digestive Endoscopy Unit, S.Agostino-Estense Hospital, Modena, Italy,Corresponding author Raffaele Manta, MD Gastroenterologia ed Endoscopia DigestivaAzienda Ospedaliera Universitaria di ModenaOspedale S.Agostino-EstenseViale Giardini Nord 1355Baggiovara, ModenaItaly+0039 059 3961216
| | - Santi Mangiafico
- Digestive Endoscopy Unit, S.Agostino-Estense Hospital, Modena, Italy
| | - Angelo Zullo
- Gastroenterology Unit, Nuovo Regina Margherita Hospital, Rome, Italy
| | - Helga Bertani
- Digestive Endoscopy Unit, S.Agostino-Estense Hospital, Modena, Italy
| | - Angelo Caruso
- Digestive Endoscopy Unit, S.Agostino-Estense Hospital, Modena, Italy
| | - Giuseppe Grande
- Digestive Endoscopy Unit, S.Agostino-Estense Hospital, Modena, Italy
| | | | | | - Luigi Pasquale
- Gastroenterology Unit, San Giuseppe Moscati Hospital, Avellino, Italy
| | - Andrea Parodi
- Gastroenterology Unit, Galliera Hospital, Genova, Italy
| | - Bastianello Germanà
- Gastroenterology and Digestive Endoscopy Unit, Belluno Hospital, Belluno, Italy
| | - Gabrio Bassotti
- Gastroenterology Unit, Department of Medicine, Perugia University, Perugia, Italy
| | - Fabio Monica
- Gastroenterology Unit, Azienda Sanitaria Universitaria Integrata, Trieste, Italy
| | - Maurizio Zilli
- Gastroenterology Unit, Azienda Sanitaria Universitaria Integrata, Udine, Italy
| | - Antonio Pisani
- Gastroenterology Section, Department of Emergency and Organ Transplantation, Bari University, Bari, Italy
| | | | - Rita Conigliaro
- Digestive Endoscopy Unit, S.Agostino-Estense Hospital, Modena, Italy
| | - Giuseppe Galloro
- Surgical Digestive Endoscopy, Department of Clinical Medicine and Surgery, Federico II University, Naples, Italy
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Singh RR, Nussbaum JS, Kumta NA. Endoscopic management of perforations, leaks and fistulas. Transl Gastroenterol Hepatol 2018; 3:85. [PMID: 30505972 DOI: 10.21037/tgh.2018.10.09] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Accepted: 10/19/2018] [Indexed: 12/14/2022] Open
Abstract
The endoscopic management armamentarium of gastrointestinal disruptions including perforations, leaks, and fistulas has slowly but steadily broadened in recent years. Previously limited to surgical or conservative medical management, innovations in advanced endoscopic techniques like natural orifice transluminal endoscopic surgery (NOTES) have paved the path towards development of endoscopic closure techniques. Early recognition of a gastrointestinal defect is the most important independent variable in determining successful endoscopic closure and patient outcome. Some devices including through the scope clips and stents have been well studied for other indications and have produced encouraging results in closure of gastrointestinal perforations, leaks and fistulas. Over the scope clips, endoscopic sutures, vacuum therapy, glue, and cardiac device occluders are other alternative techniques that can be employed for successful endoscopic closure.
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Affiliation(s)
- Ritu Raj Singh
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jeremy S Nussbaum
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nikhil A Kumta
- Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Abstract
PURPOSE OF REVIEW Gastrointestinal transmural defects are defined as total rupture of the gastrointestinal wall and can be divided into three main categories: perforations, leaks, and fistulas. Due to an increase in the number of therapeutic endoscopic procedures including full-thickness resections and the increase incidence of complications related to bariatric surgeries, there has been an increase in the number of transmural defects seen in clinical practice and the number of non-invasive endoscopic treatment procedures used to treat these defects. RECENT FINDINGS The variety of endoscopic approaches and devices, including closure techniques using clips, endoloop, and endoscopic sutures; covering techniques such as the cardiac septal occluder device, luminal stents, and tissue sealants; and drainage techniques including endoscopic vacuum therapy, pigtail, and septotomy with balloon dilation are transforming endoscopy as the first-line approach for therapy of these conditions. In this review, we describe the various transmural defects and the endoscopic techniques and devices used in their closure.
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Bowles-Cintron RJ, Perez-Ginnari A, Martinez JM. Endoscopic management of surgical complications. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2018. [DOI: 10.1016/j.tgie.2018.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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25
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Bemelman WA, Baron TH. Endoscopic Management of Transmural Defects, Including Leaks, Perforations, and Fistulae. Gastroenterology 2018; 154:1938-1946.e1. [PMID: 29454791 DOI: 10.1053/j.gastro.2018.01.067] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Revised: 01/05/2018] [Accepted: 01/06/2018] [Indexed: 02/06/2023]
Abstract
Transmural defects of the gastrointestinal tract can be classified into 3 distinct entities-leak, perforation, and fistula. Each arises from different mechanisms and is managed accordingly. Leaks occur most often after surgery, while perforations occur most often after flexible endoscopic maneuvers. Fistulae arise from a variety of mechanisms, such as an evolution from surgical leaks, as well as from specific disease states. Endoscopic management plays a vital role in the treatment of transmural defects as long as the region of interest can be accessed with the appropriate endoscopic accessories. Endoscopic approaches can be broadly classified into those that provide closure and those that provide diversion of luminal contents. With advances in technology, a myriad of devices and accessories are available that allow a tailored approach. Endoscopic approaches to leaks, perforations, and fistulae are discussed in this review.
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Affiliation(s)
- Willem A Bemelman
- Department of Surgery, The Academic Medical Center and University of Amsterdam, Amsterdam, The Netherlands
| | - Todd H Baron
- Division of Gastroenterology and Hepatology, University of North Carolina at Chapel Hill, Chapel Hill North Carolina. todd_baron.@med.unc.edu
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Assalia A, Ilivitzki A, Ofer A, Suissa A, Manassa E, Khamaysi I, Mahajna A. Management of gastric fistula complicating laparoscopic sleeve gastrectomy with biological glue in a combined percutaneous and endoscopic approach. Surg Obes Relat Dis 2018; 14:1093-1098. [PMID: 29895427 DOI: 10.1016/j.soard.2018.04.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Revised: 03/31/2018] [Accepted: 04/15/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND Laparoscopic sleeve gastrectomy (LSG) is considered as a first line treatment for morbid obesity around the globe. Leakage and subsequent gastric fistula is the most dreadful complication, which may lead to serious morbidity and even mortality. OBJECTIVES To assess the safety and efficacy of fibrin glue application in the setting of gastric fistula after LSG. SETTING University hospital, Israel. METHODS Twenty-four morbidly obese patients (mean age = 42.2 yr, mean body mass index = 42 kg/m2) developed gastric fistula after LSG. The fistula was acute in 10 patients, subacute in 9, and chronic in 5. Sixteen patients (67%) have had previous failed endoscopic interventions. Fibrin glue was applied percutaneously with fluoroscopic guidance, under endoscopic visualization. A pigtail drain was left in the distal tract to monitor and manage possible continuous leakage. RESULTS There were no complications except abdominal pain in 2 patients associated with fever in 1. Both resolved within 1 to 2 days. Fistula closure was achieved in all patients but 1 (95.8%). Closure was accomplished after a single application in 9 patients (39%), 2 applications in 8, 3 applications in 3, 5 applications in 2, and 6 applications in 1. All patients were followed with a mean time of 42.3 months (range, 20-46). CONCLUSIONS Although in most patients there was a need for multiple applications, our experience indicates that percutaneous fluoroscopic application of Fibrin glue under endoscopic visualization proved to be a simple, tolerable, and highly effective method for the treatment of selected patients with gastric fistula after LSG.
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Affiliation(s)
- Ahmad Assalia
- Department of General Surgery, Rambam Health Care Campus and the Rappaport faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel.
| | - Anat Ilivitzki
- Department of Radiology, Rambam Health Care Campus and the Rappaport faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Amos Ofer
- Department of Radiology, Rambam Health Care Campus and the Rappaport faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Alain Suissa
- Department of Gastroenterology, Rambam Health Care Campus and the Rappaport faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Elias Manassa
- Department of General Surgery, Rambam Health Care Campus and the Rappaport faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Iyad Khamaysi
- Department of Gastroenterology, Rambam Health Care Campus and the Rappaport faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Ahmad Mahajna
- Department of General Surgery, Rambam Health Care Campus and the Rappaport faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
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Kähler G. Anastomotic Leakage after Upper Gastrointestinal Surgery: Endoscopic Treatment. Visc Med 2017; 33:202-206. [PMID: 28785568 DOI: 10.1159/000475783] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Anastomotic leakages substantially influence the outcome of patients after major surgery of the upper gastrointestinal tract. Endoscopy is important for making a diagnosis and for managing anastomotic leakages. By means of endoscopic inspection of the anastomotic site, not only the size and position of dehiscences but also the blood supply of the anastomotic region and an imminent leakage can be assessed. To close anastomotic leakages, several therapeutic methods are available, i.e. stenting, clipping, and the application of glue. In the majority of cases, the endoscopic application of a sponge for permanent suction (endoscopic vacuum-assisted closure therapy) is promising.
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Affiliation(s)
- Georg Kähler
- Central Interdisciplinary Endoscopy, Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
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Sevim Y, Celik SU, Yavarifar H, Akyol C. Minimally invasive management of anastomotic leaks in colorectal surgery. World J Gastrointest Surg 2016; 8:621-626. [PMID: 27721925 PMCID: PMC5037335 DOI: 10.4240/wjgs.v8.i9.621] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 07/06/2016] [Accepted: 07/22/2016] [Indexed: 02/06/2023] Open
Abstract
Anastomotic leakage is an unfortunate complication of colorectal surgery. This distressing situation can cause severe morbidity and significantly affects the patient’s quality of life. Additional interventions may cause further morbidity and mortality. Parenteral nutrition and temporary diverting ostomy are the standard treatments of anastomotic leaks. However, technological developments in minimally invasive treatment modalities for anastomotic dehiscence have caused them to be used widely. These modalities include laparoscopic repair, endoscopic self-expandable metallic stents, endoscopic clips, over the scope clips, endoanal repair and endoanal sponges. The review aimed to provide an overview of the current knowledge on the minimally invasive management of anastomotic leaks.
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