Endotherapy of leaks and fistula

Indigenously modified endoluminal vacuum-assisted closure therapy for post-operative gastrointestinal transmural defects: Case series and review of literature

ABSTRACT

A gastrointestinal (GI) transmural defect is defined as a total rupture of the GI wall and these defects can be divided into three main categories, including perforation, leaks and fistulae. Recognition of the specific classification of the defect is important for choosing the best therapeutic modality. We present a case series of patients with gastrointestinal transmural defects which were managed with indigenously modified endoluminal vacuum-assisted closure.

Endoscopic vacuum assisted closure therapy for esophagopericardial fistula in a 16-year-old male: A case report

BACKGROUND

Esophagopericardial fistula (EPF) is a rare, life-threatening condition with limited scientific literature and no established management guidelines. This case report highlights a successful multidisciplinary approach and the innovative use of endoscopic vacuum assisted closure (endoVAC) therapy in treating this complex condition.

CASE SUMMARY

A 16-year-old male with a history of esophageal atresia and colon interposition presented with progressive chest pain, fever, and dyspnea. Imaging revealed an EPF with associated pleural and pericardial effusions. Initial management with an esophageal stent failed, prompting the use of an endoVAC system. The patient underwent multiple endoVAC device changes and received broad-spectrum antibiotics and nutritional support. The fistula successfully closed, and the patient recovered, demonstrating no new symptoms at a 6-month follow-up.

CONCLUSION

EndoVAC therapy can effectively manage EPF, providing a minimally invasive treatment option.

Engineered Regenerative and Adhesive Hydrogel for Concurrent Sealing and Healing of Enterocutaneous Fistulas

In addressing the intricate challenges of enterocutaneous fistula (ECF) treatment, such as internal bleeding, effluent leakage, inflammation, and infection, our research is dedicated to introducing a regenerative adhesive hydrogel that can seal and expedite the healing process. A double syringe setup was utilized, with dopagelatin and platelet-rich plasma (PRP) in one syringe and Laponite and sodium periodate in another. The hydrogel begins to cross-link immediately after passing through a mixing tip and exhibits tissue adhesive properties. Results demonstrated that PRP deposits within the pores of the cross-linked hydrogel and releases sustainably, enhancing its regenerative capabilities. The addition of PRP further improved the mechanical properties and slowed down the degradation of the hydrogel. Furthermore, the hydrogel demonstrated cytocompatibility, hemostatic properties, and time-dependent macrophage M1 to M2 phase transition, suggesting the anti-inflammatory response of the material. In an in vitro bench test simulating high-pressure fistula conditions, the hydrogel effectively occluded pressures up to 300 mmHg. In conclusion, this innovative hydrogel holds promise for ECF treatment and diverse fistula cases, marking a significant advancement in its therapeutic approaches.

Endoscopic Intervention for Anastomotic Leakage After Gastrectomy

Anastomotic leaks and fistulas are significant complications of gastric surgery that potentially lead to increased postoperative morbidity and mortality. Surgical intervention is reserved for cases with severe symptoms or hemodynamic instability; however, surgery carries a higher risk of complications. With advancements in endoscopic treatment options, endoscopic approaches have emerged as the primary choice for managing these complications. Endoscopic clipping is a traditional method comprising 2 main categories: through-the-scope clips and over-the-scope clips. Through-the-scope clips are user friendly and adaptable to various clinical scenarios, whereas over-the-scope clips can close larger defects. Another promising approach is endoscopic stent insertion, which has shown a high success rate for leak closure, although vigilant monitoring is required to monitor stent migration. Infection control is essential in post-surgical leakage cases, and endoscopic internal drainage provides a relatively safe and noninvasive means to manage fluids, contributing to infection control and wound healing promotion. Endoscopic suturing offers full-thickness wound closure, but requires additional training and endoscopic versatility. As a promising tool, endoscopic vacuum therapy potentially surpasses stent therapy by draining inflammatory materials and closing defects. Furthermore, the use of tissue sealants, such as fibrin glue and cyanoacrylate, has been reported to be effective in selected situations. The choice of endoscopic device should be tailored to individual cases and specific patient conditions, with careful consideration of the nature of the defect. Further extensive studies involving larger patient populations are required to provide more robust evidence on the efficacy of endoscopic approach in managing post-gastric anastomotic leaks.

A case report of a colouterine fistula treatment: when the patient chooses the steeplechase

Colouterine fistula is a rare disease that is primarily treated using surgical approaches. Although invasive surgery is controversial in terms of techniques and results, minimally invasive endoscopic treatments have not been widely described. However, because it is rare for these fistulas to close spontaneously, surgical treatment is often mandatory. Appropriate management of colouterine fistula is complicated, especially when the patient refuses surgery. In this case study, we provide the first description of a minimally invasive endoscopic treatment of an iatrogenic colouterine fistula using a self-expandable metallic stent after an over-the-scope clip malposition.

Endoscopic Vacuum Therapy of Upper Gastrointestinal Anastomotic Leaks: How to Deal with the Challenges (with Video)

Anastomotic leaks after gastrointestinal surgery have an important impact on surgical outcomes because of the high morbidity and mortality rates. Multiple treatment options exist requiring an individualized patient-tailored treatment plan after multidisciplinary discussion. Endoscopic vacuum therapy (EVT) is a novel treatment option that is nowadays recognized as an effective and useful endoscopic approach to treat leaks or perforations in both the upper and lower gastrointestinal tract. EVT has a very good safety profile. However, it is a time-consuming endeavour requiring engagement from the endoscopist and understanding from the patient. To the unexperienced, the EVT technique may be prone to several hurdles which may deter endoscopists from using it and depriving patients from a potentially life-saving therapeutic option. The current review highlights the possible difficulties of the EVT procedure and aims to provide some practical solutions to facilitate its use in daily clinical practice. Personal tips and tricks are shared to overcome the pre-, intra- and post-procedural hurdles. An instructive video of the procedure helps to illustrate the technique of EVT.

A Case of Gastric Perforation Caused by Excessive Insufflation during Upper Gastrointestinal Endoscopy: Nonoperative Management

Introduction

Upper gastrointestinal endoscopy is used to diagnose and treat upper gastrointestinal diseases, but it can also cause complications, including perforation. Perforation is a serious complication, so it is important to be aware of the risk factors in advance and to take precautions to prevent it.

Case Presentation

We report a case of gastric perforation caused by excessive insufflation during upper gastrointestinal endoscopy in a 64-year-old man with a history of multiple active gastric ulcers. During the endoscopy, the patient did not cooperate and insufflation was performed for a prolonged period of time. This led to a mucosal laceration and a hole suspected to be a perforation on the lesser curvature of the gastric body. The patient was treated nonsurgically with fasting, intravenous fluids, antibiotics, intravenous proton pump inhibitors, and blood transfusions. No leakage was observed on the follow-up computed tomography scan, and the perforation site was completely healed 2 months later.

Conclusion

In this case, the patient was successfully treated with conservative therapy alone. The treatment of gastric perforation caused by endoscopy has shifted toward conservative therapy in recent years.

Outpatient closure in a late colo-cutaneous postoperative anastomotic leak managed with EVAC in Bucaramanga, Colombia. Case report

Introduction

After Hartmann-type colostomy, the adequate selection of some patients allows reversal and closure of the colostomy, however, this reversal is not free of complications. Among complications, anastomotic leaks and fistulae can have functional, economic, and oncological consequences. Complications have been treated with surgery; yet, this management has changed considerably in recent years, moving towards less invasive therapies.

Presentation of case

This is the report of a 42-year-old man with a history of closed abdominal trauma with perforation of the sigmoid colon managed with a Hartmann-type colostomy. Six months later, he was admitted for a Hartmann reversal procedure without immediate complications. He was assessed again after 4 months observing a small area of erythema and periumbilical edema. EUS was performed without evidence of collections. Colonoscopy evidenced a 7-mm fistulous orifice in the colocolonic anastomosis. The Endo-VAC system was used, performing endoscopically exchanges twice a week following a low-residue diet. The procedure was performed on an outpatient basis and the closure of the leak hole in the colonic anastomosis was achieved in 30 days.

Discussion

Endoluminal vacuum therapy or EVAC, is an adaptation of the therapy used for negative pressure wound closure. This minimally invasive technique has been used for the treatment of gastrointestinal leaks and fistulae in selected patients and within a hospital setting. Our case presents the use of this technique in a late colocutaneous postoperative leak on an outpatient basis.

Conclusion

To the best of our knowledge we report the first case of a late colocutaneous anastomotic leak managed with EVAC on an outpatient basis.

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Endoluminal vacuum therapy (EVAC) is an adaptation of the therapy used for negative pressure wound closure.

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We report the first case of a late colocutaneous postoperative fistula managed with EVAC on an outpatient basis.

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In selected patients, the EndoVac therapy can be performed using easily accessible and low-cost supplies.

Bloodstream Infection in Patients With Intestinal Fistula: A Retrospective Study

BACKGROUND

To delineate the clinical characteristics of intestinal fistula patients with Bloodstream infection (BSI).

METHODS

Retrospective case series in Surgical Intensive Care Unit (SICU), Shanghai Ninth People's Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China. Among a cohort of 204 patients with a diagnosis of intestinal fistula, 46 who were complicated with BSI were analysed retrospectively. Data was collected from January 1, 2018 to February 1, 2020.

RESULTS

Among the 204 patients with intestinal fistula, 46 patients showed positive blood cultures, which clearly had BSIs. Parenteral nutrition (PN) time (OR 1.08, 95% CI 1.04∼1.12, P < 0.01), transferred from external ICU (OR 3.68, 95% CI 1.48∼9.17, P = 0.01), septic shock (OR 4.61, 95% CI 1.77∼11.97, P < 0.01), APACHE II (OR 1.11, 95% CI 1.01∼1.22, P = 0.04) were significantly associated with BSI in patients with intestinal fistula. When APACHE II score exceeds 12.0 points or PN time exceeds 18.0 D, the chance of BSI in patients with intestinal fistula increases significantly. In addition, compared with the non-BSI group, BSI group had a higher mortality and expenses in ICU, longer stay in ICU and total hospital stay, and worse quality of life (all P < 0.05). A total of 105 isolates from samples (including sputum, pus and blood) of 46 patients in the BSI group, among which were mainly gram negative rods and fungi, as well as blood isolates. Importantly, in patients with intestinal fistula, BSIs caused by fungi accounted for 23.4%.

CONCLUSION

Long-term PN, transfer from external ICU, septic shock, and higher APACHE II scores are often associated with an increased probability of BSIs in patients with intestinal fistula and a higher mortality. Gram-negative bacteria are the main pathogenic bacteria in intestinal fistula patients with BSI, and patients with intestinal fistula are more likely to develop fungal BSIs.

[Endoscopy on the surgical intensive care unit]

Endoscopy is most frequently performed in intensive care units (ICU) for gastrointestinal bleeding; however, there are other indications for performing an endoscopy on the ICU. This article shows the indications for this, the background and the peri-interventional and postinterventional management. The endoscopic placement of a postpyloric feeding tube is a well-established procedure. For anastomotic leakage in the esophagus and rectum, the endoscopic vacuum therapy is the treatment of choice. Gastrointestinal motility disorders are a frequent phenomenon in critically ill patients and are associated with increased mortality. With a cecal diameter > 9-12 mm, endoscopic decompression can be performed; however, this is associated with an increased risk of perforation and should only be carried out after the failure of conservative treatment.

The success of Eso-SPONGE® therapy in the treatment of anastomotic dehiscence after Ivor-Lewis subtotal esophagectomy: A case report

Introduction

Eso-SPONGE® has proved to be an excellent method for the treatment of persistent dehiscence of the intrathoracic esophagogastric anastomosis during the operation of subtotal esophagectomy sec. Ivor Lewis.

Clinical case presentation

The case presented is of a 72-year-old patient with esophageal adenocarcinoma (ADK) who underwent sub-total esophagectomy and esophagoplasty sec. Ivor Lewis complicated by an esophageal leak. The Eso-SPONGE® therapy has been successful halving the index of inflammation after the first two sessions and generation of a neowall after seven sessions.

Discussion

Eso-SPONGE® therapy has proven to be a valuable resource as a treatment for esophageal anastomotic dehiscences because it is easily repeatable in suburban centers, provided that they have a digestive endoscopy specialized in the positioning process.

Conclusions

Eso-SPONGE® is a minimally invasive method that delivers excellent results in the treatment of fragile patients, such as those who have post-esophageal anastomotic dehiscence.

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Anastomotic dehiscence is an adverse event in esophageal surgery.

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Eso-SPONGE® is an excellent method to treat the esophageal post-surgery dehiscence.

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Eso-SPONGE® has provided better results than previous methods.

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Eso-SPONGE® is easily repeatable even in not-expert centers.

Novel through-the-scope twin clip for the closure of GI wounds: the first experimental survival study in pigs (with videos)

BACKGROUND AND AIMS

We developed a through-the-scope twin clip (TTS-TC) for closing GI wounds. The objective of this study was to evaluate the efficacy and safety of the TTS-TC in GI wound closure.

METHODS

GI nonperforating and perforating wounds (≥2.5 cm) were created in live pigs. TTS-TCs were used to convert the large wounds into small wounds. The remaining small wounds were closed using conventional through-the-scope clips (TTSCs). The follow-up period was 1 month. Location and size of the wound, time of wound closure, intraoperative and postoperative adverse events, and conditions of wound healing were investigated.

RESULTS

Thirteen wounds were created in 5 live pigs, including 2 gastric nonperforating and 3 perforating wounds and 5 large intestinal nonperforating and 3 perforating wounds. The mean long and short diameters of the wounds were 4.1 (± .9) cm and 3.4 (± .7) cm, respectively. All wounds were successfully closed using the TTS-TCs combined with TTSCs. The total mean time for wound closure was 9.2 (± 5.3) minutes, and the mean time for using the TTS-TCs was 3.9 (± 4.7) minutes. During the 1-month follow-up period, no bleeding, perforation, or death occurred; all wounds healed with scar formation; and all TTS-TCs detached spontaneously.

CONCLUSIONS

The TTS-TC was successfully used to close large-sized GI wounds. The TTS-TC is a promising tool for large-size wound closure under flexible endoscopy.

Safety and effectiveness of endoluminal vacuum-assisted closure for esophageal defects: Systematic review and meta-analysis

Background and study aims  Esophageal defects (leaks, fistulas, and perforations) are associated with significant morbidity and mortality. Endoluminal vacuum-assisted closure (EVAC) is a novel intervention that entails the use of sponges in the defect along with negative pressure to achieve granulation tissue formation and healing and has been gaining popularity. We performed a systematic review and pooled analysis of available literature to assess the safety and effectiveness of EVAC for esophageal defects. Patients and methods  We queried PubMed/Medline, Embase, Cochrane, and Web of Science through September 25, 2020 to include all pertinent articles highlighting the safety and effectiveness profile of EVAC for esophageal defects. Pooled rates, 95 % confidence intervals (CIs), and heterogeneity ( I ² ) were assessed for each outcome. Results  A total of 18 studies with 423 patients were included (mean age 64.3 years and males 74.4 %). The technical success for EVAC was 97.1 % (CI: 95.4 %-98.7 %, I ²  = 0 %). The clinical success was 89.4 % (CI: 85.6 %-93.1 %, I ²  = 36.8 %). The overall all-cause mortality and adverse events (AEs) noted were 7.1 % (CI: 4.7 %-9.5 %, I ²  = 0 %) and 13.6 % (CI: 8.0 %-19.1 %, I ²  = 68.9 %), respectively. The pooled need for adjuvant therapy was 15.7 % (CI: 9.8 %-21.6 %, I ²  = 71.1 %). Conclusions  This systematic review and meta-analysis showed high rates of technical success, clinical success, and low all-cause mortality and AEs using EVAC. Although the technique is a promising alternative, the lack of comparative studies poses a challenge in making definite conclusions regarding use of EVAC compared to other endoscopic modalities, such as clips and stents.

A Comprehensive Review of Endoscopic Management of Sleeve Gastrectomy Leaks

BACKGROUND

Bariatric surgery leaks result in significant morbidity and mortality. Experts report variable therapeutic approaches, without uniform guidelines or consensus.

OBJECTIVE

To review the pathogenesis, risk factors, prevention, and treatment of gastric sleeve leaks, with a focus on endoscopic approaches. In addition, the efficacy and success rates of different treatment modalities are assessed.

DESIGN

A comprehensive review was conducted using a thorough literature search of 5 online electronic databases (PubMed, PubMed Central, Cochrane, EMBASE, and Web of Science) from the time of their inception through March 2020. Studies evaluating gastric sleeve leaks were included. MeSH terms related to "endoscopic," "leak," "sleeve," "gastrectomy," "anastomotic," and "bariatric" were applied to a highly sensitive search strategy. The main outcomes were epidemiology, pathophysiology, diagnosis, treatment, and outcomes.

RESULTS

Literature search yielded 2418 studies of which 438 were incorporated into the review. Shock and peritonitis necessitate early surgical intervention for leaks. Endoscopic therapies in acute and early leaks involve modalities with a focus on one of: (i) defect closure, (ii) wall diversion, or (iii) wall exclusion. Surgical revision is required if endoscopic therapies fail to control leaks after 6 months. Chronic leaks require one or more endoscopic, radiologic, or surgical approaches for fluid collection drainage to facilitate adequate healing. Success rates depend on provider and center expertise.

CONCLUSION

Endoscopic management of leaks post sleeve gastrectomy is a minimally invasive and effective alternative to surgery. Their effect may vary based on clinical presentation, timing or leak morphology, and should be tailored to the appropriate endoscopic modality of treatment.

A pilot human study on newly designed closure clips in endoscopic closure of giant gastrointestinal perforation using a continuous closing method

BACKGROUND

A large gastrointestinal perforation is a serious and even life-threatening clinical condition. Current endoscopic techniques for closing large gastrointestinal perforation have limitations. Building upon our recent findings in a porcine model, this pilot human study aimed to evaluate the safety, feasibility, and effectiveness of a novel endoscopic technique using newly designed closure clips for closure of giant gastrointestinal perforation.

METHODS

A total of 18 patients who underwent endoscopic submucosal dissection (ESD) and developed giant gastrointestinal perforation > 2 cm in diameter were enrolled in this study. The newly designed closure clips, consisting of a sewing clip and knotter, were applied in endoscopic closure of the gastrointestinal perforations using a continuous suturing method. The safety, feasibility, and effectiveness were subsequently assessed in these patients.

RESULTS

Endoscopic closure of the giant perforation was achieved in all patients. In evaluation of safety and effectiveness of this technique with the new closure clips and the continuous suturing method, no obvious intraoperative complications (e.g., bleeding, abdominal infection) occurred in the studied patients. Furthermore, on 1-month follow-up gastric endoscopy, all the patients showed complete closure of the gastrointestinal perforations, and no clinical signs of specific abnormalities or symptoms were observed.

CONCLUSION

This novel technique has been shown to be safe, effective, and feasible for the treatment of giant gastrointestinal perforation.

Effective Endoscopic Closure of Cholecysto-duodenal and Transverse Colon Fistulas Due to Squamous Cell Carcinoma of the Gallbladder Using Polyglycolic Acid Sheets and a Covered Metal Stent

An 81-year-old woman presented with abdominal distension and right hypochondrial pain. Abdominal contrast computed tomography and magnetic resonance imaging revealed an 11-cm gallbladder tumor. The patient was diagnosed with squamous cell carcinoma of the gallbladder by endoscopic ultrasound-guided fine-needle aspiration from the gastric antrum. Thereafter, the gallbladder tumor enlarged, and cholecysto-duodenal and transverse colon fistulas were formed. A covered metal stent was placed on the transverse colon, and polyglycolic acid sheets were injected into the duodenum to close the fistulas endoscopically. Endoscopic closure is less invasive than surgery and considered effective for patients with poor general health conditions.

Nanocomposite hyaluronic acid-based hydrogel for the treatment of esophageal fistulas

Fistulas are abnormal connections between two body parts that can impair the quality of life. The use of biological glues represents the least invasive procedure to fill the fistula; however, it is limited by the need of multiple injections, the persistence of infection and the failure in the treatment of high-output fistulas. We describe herein the use of an injectable nanocomposite hydrogel that is able to form in situ a tissue-mimicking matrix as an innovative material for the treatment of esophageal fistulas. Injectable hydrogels that have the dual advantage of being implantable with a minimally invasive approach and of adapting their shape to the target cavity, while the introduction of mesoporous silica nanoparticles opens the possibility of drug/biomolecules delivery.

The hydrogel is based on hyaluronic acid (HA), the crosslinking process occurs at physiological conditions leading to a hydrogel made of >96% by water and with a large-pore micro-architecture. The kinetic profile of the hydrogel formation is studied as a function of HA molecular weight and concentration with the aim of designing a material that is easily injectable with an endoscopic needle, is formed in a time compatible with the surgical procedure and has final mechanical properties suitable for cell proliferation. The in vivo experiments (porcine model) on esophageal-cutaneous fistulas, showed improved healing in the animals treated with the hydrogel compared with the control group.

Postoperative Intestinal Fistula in Primary Advanced Ovarian Cancer Surgery

Background

Advanced ovarian cancer (AOC) requires an aggressive surgery with large visceral resections in order to achieve an optimal or complete cytoreduction and increase the patient’s survival. However, the surgical aggressiveness in the treatment of AOC is not exempt from major complications, such as the gastrointestinal fistula (GIF), which stands out among others due to its high morbidity and mortality.

Methods

We evaluated the clinicopathological features in patients with AOC and their association with GI. Data for 107 patients with AOC who underwent primary debulking surgery were analyzed retrospectively. Clinicopathological features, including demographic, surgical procedures and follow-up data, were analyzed in relation to GIF.

Results

GIF was present in 11% of patients in the study, 5 (4.5%) and 7 (6.4%) of colorectal and small bowel origin, respectively. GIF was significantly associated with peritoneal cancer index (PCI) >20, more than 2 visceral resections, and multiple digestive resections. Overall and disease-free survival were also associated with GIF. Multivariate analysis identified partial bowel obstruction and operative bleeding as independent prognostic factors for survival. The presence of GIF is positively associated with poor prognosis in patients with AOC.

Conclusion

Given the importance of successful cytoreductive surgery in AOC, the assessment of the amount of tumor and the aggressiveness of the surgery to avoid the occurrence of GIF become a priority in patients with AOC.

New technologies and advances in weight loss therapy

Bariatric surgery is the most effective treatment for obesity and its comorbidities but there are barriers that prevent its general acceptance. The growing obesity epidemic has resulted in the need for the creation of new, less invasive treatments, with a wide margin of safety and effectiveness for conditioning weight loss, at least greater than that resulting from treatment based on diet and exercise. Emerging therapies include devices that are endoscopically placed and removed, classified as: space-occupying devices, restrictive or anatomic-remodeling procedures, endoluminal bypass, and duodenal mucosal resurfacing. Percutaneous techniques and less invasive surgeries are also included. In general, results have shown improvement in glucose metabolism in diabetic patients. With respect to weight loss, results do not surpass those of bariatric surgery, but are better than results with conservative treatment (diet and exercise) and have a low rate of adverse events. Clinical use of a new technique should be carried out within a multidisciplinary management program that includes nutritional, psychologic, physical activity, and medical support. It must be understood that novel therapies are not being created to substitute bariatric surgery, but rather to increase treatment options in the general population, with greater reach and impact. The aim of the present study was to provide an up-to-date literature review on emerging technologies for the treatment of obesity.

The role of endoprostheses in the treatment of leaks after laparoscopic sleeve gastrectomy. Analysis of a Spanish registry

It has been suggested that endoprostheses are an effective treatment for fistulae after sleeve gastrectomy, but the results published are very variable. To analyze the effectiveness of stents as treatment of leakage after sleeve gastrectomy, the Spanish Society of Obesity Surgery (SECO) and the Obesity Division of the Spanish Association of Surgeons (AEC) set up a National Registry to record treatments of leaks after sleeve gastrectomy. We have analyzed patients with leaks after sleeve gastrectomy and treated with endoprostheses: 19 medical centers reported the use of endoprostheses, where 51 endoprostheses were used in 42 patients (34 women/8 men, mean age: 43.8 years, BMI: 47.6). Global effectiveness was 45%, with a complication rate of 35%. Uni- and multivariate analyses detected no factors influencing the efficacy of treatment. A larger diameter bouggie used to calibrate the stomach was related to a higher incidence of complications. No factors were found related with better stent efficacy. The effectiveness of a second stent was very low when the previous one had not been effective.

The Use of the Overstitch to Close Perforations and Fistulas

Endoscopic suturing allows for select patients with perforations, leaks, and fistulas to be managed endoscopically. Experience with the Overstitch endoscopic suturing device suggests it may be superior to endoclips in the management of perforations, because of its ability to achieve full-thickness suturing and create an airtight closure. Although successful closure of leaks and fistulas using the Overstitch device has been described, additional therapy with a multimodality approach is often required because of inherent challenges with fistula recurrence. This article reviews the existing literature on the Overstitch endoscopic suturing system specifically in the management of gastrointestinal perforations, leaks, and fistulas.

Spontaneous Gastrojejunal Fistulization after Roux-en-Y Bypass Surgery: A Case Report and Review of Literature

Fistula development is an uncommon but well-recognized complication following Roux-en-Y gastric bypass (RYGB). The broad spectrum of clinical presentation represents a challenge at the time of diagnosis. We present the case of a patient who developed gastrojejunal fistulization after gastric bypass surgery.

Recent advancements in the minimally invasive management of esophageal perforation, leaks, and fistulae

INTRODUCTION

Historically, the gold standard management of esophageal perforations, leaks, and fistulae has been traditional open surgery, but it is associated with significant morbidity and mortality. Minimally invasive approaches offer alternatives to surgery in treating hemodynamically stable patients with such defects. In this review article, we will discuss the recent advancements in the minimally invasive management of esophageal perforations, leaks, and fistulas.

AREAS COVERED

This review includes information from case reports, case series, and clinical trials on minimally invasive management of esophageal perforations, leaks, and fistulas. The focus is on the devices, outcomes, and application of the technology.

EXPERT COMMENTARY

Minimally invasive treatment represents significant progress in the management of esophageal perforations, leaks, and fistulas. Based on current evidence, it seems safe and effective but it is evolving and more studies are needed to help draw definitive conclusions.

Role of endoscopic vacuum therapy in the management of gastrointestinal transmural defects

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.

Systematic review of endoluminal vacuum-assisted therapy as salvage treatment for rectal anastomotic leakage

BACKGROUND

Endoluminal vacuum-assisted therapy (EVT) has been introduced recently to treat colorectal anastomotic leakage. The aim of this study was to evaluate the safety and efficacy of EVT in the treatment of anastomotic leakage and rectal stump insufficiency after Hartmann's procedure.

METHODS

A systematic search of MEDLINE, Scopus and Cochrane databases was performed using search terms related to EVT and anastomotic leakage or rectal stump insufficiency in line with the PRISMA checklist. Observational studies, RCTs and case series studies published to July 2017 were included. Primary outcomes of the review were the success of EVT, defined as complete or partial healing of the anastomotic defect and associated cavity, and the rate of stoma reversal after EVT. Secondary outcomes included the duration of treatment to complete healing, complications of treatment and the need for further intervention. A meta-analysis was conducted. The potential effect of clinical confounders on the failure of EVT was investigated using the random-effects meta-regression model.

RESULTS

Of 476 articles identified, 17 studies reporting on 276 patients were ultimately included. The weighted mean rate of success was 85·3 (95 per cent c.i. 80·1 to 90·5) per cent, with a median duration from inception of EVT to complete healing of 47 (range 40-105) days. The weighted mean rate of stoma reversal across the studies was 75·9 (64·6 to 87·2) per cent. Twenty-five patients (9·1 per cent) required additional interventions after EVT. Thirty-eight patients (13·8 per cent) developed complications. The weighted mean complication rate across the studies was 11·1 (6·0 to 16·2) per cent. Variables significantly associated with failure included preoperative radiotherapy, absence of diverting stoma, complications and male sex.

CONCLUSION

EVT is associated with a high rate of complete healing of anastomotic leakage and stoma reversal. It is an effective option in appropriately selected patients with anastomotic leakage.

Endoscopic vacuum assisted wound closure (EVAC) device to treat esophageal and gastric leaks: assessing time to proficiency and cost

BACKGROUND

Endoluminal vacuum therapy (EVAC) is an emerging procedure used to treat anastomotic leaks and/or perforations that would otherwise require surgery. The aim of this study was to determine time to proficiency in EVAC and the cost effectiveness of the procedure.

METHODS

We retrospectively reviewed a prospectively maintained IRB approved database for all patients undergoing EVAC after esophageal and gastric complications between October 2013 and December 2017. Proficiency was determined by obtaining predicted estimates and analyzing the point at which average procedure time plateaued based on case volume. Total cost was calculated based on supplies and location where the procedure was performed.

RESULTS

There were 50 patients (17 males, 33 female), with a mean age of 52.1 years. EVAC was placed in 23 (46%) patients with esophageal injuries and 28 (56%) with gastric injuries. Two advanced endoscopists performed all EVAC procedures in this study (1 surgeon, 1 gastroenterologist). The average procedure time for all patients was 43.5 min and the average wheel in/wheel out time for all patients was 75.6 min. Analysis of the trend based on average procedure times for EVAC revealed that proficiency was obtained after 10 cases. Total cost of the procedure is significantly lower in the GI lab compared to the operating room ($4528 vs. $11889). The majority of EVAC were performed in the GI lab (62%) compared to the operating room (38%).

CONCLUSION

Successful outcomes in managing anastomotic leaks or intestinal perforations non-operatively has led to an increased interest in EVAC. For advanced endoscopists, time to proficiency is approximately 10 cases. Performing the procedure in the GI lab has a 2.5 reduction in total cost compared to the operating room.

Endoscopic Full-Thickness Defects and Closure Techniques

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.

Conservative management for iatrogenic gastric perforation by transesophageal echocardiography

Background

Though several cases of upper gastrointestinal tract injury caused by transesophageal echocardiography (TEE) have been reported, gastric perforation is very rare. Herein, we report the case of TEE-associated gastric perforation that was successfully treated conservatively.

Case presentation

An 82-year-old man underwent mitral valve repair. Postoperative esophagogastroduodenoscopy and computed tomography revealed gastric perforation. Surgical treatment was initially considered, but conservative management was selected to avoid increasing operative stress, to minimize the need for total gastrectomy (including the lower esophagus), and to minimize the risk of a potential intraperitoneal infection spreading to the thoracic cavity.

Conclusion

Conservative management of gastric perforation can be successful even when the perforation is recognized later than 12 h following the event, provided that there are no abdominal symptoms and no signs of peritoneal effusion or sepsis. Our experience suggests that conservative management is a feasible option for treating TEE-associated gastric perforation in appropriately selected cases.

Efficacy and Safety of Stents in the Treatment of Fistula After Bariatric Surgery: a Systematic Review and Meta-analysis

Fistula development is a serious complication after bariatric surgery. We performed a systematic review and meta-analysis to assess the efficacy of fistula closure and complications associated with endoscopic stent treatment of fistulas, developed after bariatric surgeries, particularly Roux-en-Y gastric bypass (RYGB) and gastric sleeve (GS). Studies involving patients with fistula after RYGB or GS and those who received stent treatment only were selected. The analyzed outcomes were overall success rate of fistula closure, mean number of stents per patient, mean stent dwelling time, and procedure-associated complications. Current evidence from identified studies demonstrates that, in selected patients, endoscopic stent treatment of fistulas after GS or RYGB can be safe and effective.

Management of gastric fistula complicating laparoscopic sleeve gastrectomy with biological glue in a combined percutaneous and endoscopic approach

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.

Defunctioning ileostomy reduces leakage rate in rectal cancer surgery - systematic review and meta-analysis

Objectives

The role of a defunctioning ileostomy in every anterior rectal resection with total mesorectal excision (TME) is still controversial. In this study, we aimed to review the current literature to determine the impact of ileostomy creation on postoperative outcomes in patients undergoing anterior rectal resection with TME.

Methods

MEDLINE, Embase and Cochrane Library were searched for eligible studies. We analyzed data up to October 2017. Eligible studies had to compare patients with vs. without a defunctioning ileostomy in rectal cancer surgery and comprise data on anastomotic leakage in both groups. The primary outcome was anastomotic leakage. Secondary outcomes included the complication rate, mortality, reoperation rate, length of hospital stay and 30-day readmission.

Results

Initial search yielded 1,966 articles. Thorough evaluation resulted in 13 eligible articles which were analyzed. Leakage rate (RR = 0.43, 95% CI 0.28-0.67) and the number of reoperations (RR = 0.62, 95% CI 0.40-0.94) were significantly lower in the defunctioning stoma group. Morbidity was significantly higher in the stoma group (RR = 1.32, 95% CI 1.05–1.65). Analysis of mortality, length of hospital stay and readmission rate did not show any significant differences.

Conclusion

A defunctioning ileostomy may decrease the anastomotic leakage rate, additionally significantly reducing the risk of reoperations but it may also increase the overall complication rate. The presence of the protective stoma has no effect on mortality, length of hospital stay and readmission rate.

Use of a novel technique to manage gastrointestinal leaks with endoluminal negative pressure: a single institution experience

BACKGROUND

Perforations and anastomotic leaks of the gastrointestinal tract are severe complications, which carry high morbidity and mortality and management of these is a multi-disciplinary challenge. The use of endoluminal vacuum (EVAC) therapy has recently proven to be a useful technique to manage these complications. We report our institution's experience with this novel technique in the chest, abdomen, and pelvis.

METHODS

This is a retrospective review of an IRB approved registry of all EVAC therapy patients from July 2013 to December 2016. A total of 55 patients were examined and 49 patients were eligible for inclusion: 15 esophageal, 21 gastric, 3 small bowel, and 10 colorectal defects. The primary endpoint was closure rate of the GI tract defect with EVAC therapy.

RESULTS

Fifteen (100%) esophageal defects closed with EVAC therapy. Mean duration of therapy was 27 days consisting of an average of 6 endosponge changes every 4.8 days. Eighteen (86%) gastric defects closed with EVAC therapy. Mean duration of therapy was 38 days with a mean of 9 endosponge changes every 5.3 days. Three (100%) small bowel defects closed with EVAC therapy. Mean duration of therapy was 13.7 days with a mean of 2.7 endosponge changes every 4.4 days. Six (60%) colorectal defects closed with EVAC therapy. Mean duration of therapy was 23.2 days, consisting of a mean of 6 endosponge changes every 4.0 days. There were two deaths, which were not directly related to EVAC therapy and occurred outside the measured 30-day mortality.

CONCLUSION

Our experience demonstrates that EVAC therapy is feasible and effective for the management of gastrointestinal perforations/leaks throughout the GI tract and can be considered as a safe alternative to surgical intervention in select cases.

An Endoscopic Nasomediastinal Approach to a Mediastinal Abscess Developing after Zenker's Diverticulectomy

Zenker's diverticulum is the most frequent symptomatic diverticulum of the esophagus, but the prevalence is <0.1%. The optimal treatment is surgery. Here, we present a nasomediastinal drainage approach to treatment of a mediastinal abscess, developing in the late postoperative period and attributable to leakage from the staple line.

Review article including treatment algorithm: endoscopic treatment of luminal complications after bariatric surgery

The worldwide number of performed bariatric surgeries is increasing continuously, whereas laparoscopic Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy are conducted most frequently. Alongside with the usual post-operative and metabolic complications, luminal complications such as anastomotic bleeding, ulceration, leakage, fistula formation, enlargement and stenosis of the anastomosis may occur. Evolution of interventional endoscopy frequently allows endoscopic management of complications, avoiding surgical interventions in most cases. Here, we review the various luminal complications after bariatric surgery with a focus on their endoscopic management.

Non-healing post-surgical fistulae: treatment with image-guided percutaneous injection of cyanoacrylic glue

OBJECTIVES

To present the results of our experience with cyanoacrylic glue percutaneous injection to treat post-surgical non-healing enteric fistulae after failure of standard treatments.

METHODS

Eighteen patients (14 males; age range 33-84, mean 69 years) were treated for a non-healing post-surgical enteric fistula after failure of standard treatments. Under computed tomography and/or fluoroscopic guidance, a mixture of cyanoacrylic glue (Glubran 2, GEM, Viareggio, Italy) and ethiodized oil was injected at the site of the fistula. Fistula was considered healed when no material was drained by the percutaneous drainage and a subsequent computed tomography confirmed the disappearance of any fluid collection.

RESULTS

In all cases, it was possible to reach the site of the fistula using a percutaneous access. A median of 1 injection (range 1-5) was performed. Fistula healing was achieved in 16/18 (89 %) patients. One patient died for other reasons before fistula healing. Median time for fistula healing was 0 days (mean 8, range 0-58 days). No complications occurred. Reoperation was needed in one patient.

CONCLUSIONS

Percutaneous injection of cyanoacrylic glue is feasible, safe, and effective to treat non-healing post-surgical enteric fistulae. It may represent a further option to avoid surgical reoperation in frail patients.

Endoscopic treatment of leak at the tip of the "J" ileal pouch

Background and study aims The tip of the "J" of the ileal pouch is the vulnerable location for leak after restorative proctocolectomy, which has normally been treated with surgery. We aimed to describe a novel endoscopic method to treat the same. Patients and methods A cohort of 12 consecutive patients with a leak at the tip of the "J" was identified in our prospectively maintained Pouch Registry. The endoscopic over-the-scope clipping (OTSC) system was used for the closure of the leak. Results Eight patients (66.6 %) achieved complete closure of the leak documented by endoscopy confirmed with guidewire and/or contrasted pouchogram, with 6 requiring a single endoscopic session and 2 undergoing a repeat session. Four patients (33.3 %) had a persistent leak and required surgical intervention, of whom 1 developed abscess in the pre-spine region 14 days after the endoscopic procedure and underwent pouch revision surgery. Conclusions OSTC appears to be safe and effective in treating the leak at the tip of the "J" in the majority of patients.

New devices and techniques for endoscopic closure of gastrointestinal perforations

Gastrointestinal perforations, which need to be managed quickly, are associated with high morbidity and mortality. Treatments used to close these perforations range from surgery to endoscopic therapy. Nowadays, with the development of new devices and techniques, endoscopic therapy is becoming more popular. However, there are different indications and clinical efficacies between different methods, because of the diverse properties of endoscopic devices and techniques. Successful management also depends on other factors, such as the precise location of the perforation, its size and the length of time between the occurrence and diagnosis. In this study, we performed a comprehensive review of various devices and introduced the different techniques that are considered effective to treat gastrointestinal perforations. In addition, we focused on the different methods used to achieve successful closure, based on the literature and our clinical experiences.

Endoscopic Closure for Full-Thickness Gastrointestinal Defects: Available Applications and Emerging Innovations

Full-thickness gastrointestinal defects such as perforation, anastomotic leak, and fistula are severe conditions caused by various types of pathologies. They are more likely to require intensive care and a long hospital stay and have high rates of morbidity and mortality. After intentional full-thickness opening of hollow organs for natural orifice transluminal endoscopic surgery, safe and secure closure is urgently required. The currently available advanced endoscopic closing techniques have a major role in the treatment of full-thickness gastrointestinal defects. Appropriate usage of these techniques requires taking into account their advantages and limitations during practical application. We reviewed the available endoscopic modalities, including endoscopic clips, stents, vacuum-assisted closure, gap filling, and suturing devices, discussed their advantages and limitations when treating full-thickness gastrointestinal defects, and explored emerging innovations, including a novel endoluminal surgical platform for versatile suturing and a cell-laden scaffold for effective gap filling. Although these emerging technologies still require further pre-clinical and clinical trials to assess their feasibility and efficacy, the available modalities may be replaced and refined by these new techniques in the near future.