Endotherapy of leaks and fistula

Abstract

Perforations, leaks and fistula involving gastrointestinal (GI) tract are increasing encountered in clinical practice. There is a changing paradigm for their management with surgical approach being replaced by conservative approach including endoscopic therapy. Clips (through the scope and over the scope) and covered stent are front runners for endotherapy for GI leaks and fistula. Over the scope clips introduced recently, can treat larger defects compared to through the scope clips. Covered stents are suited for larger defects and those associated with luminal narrowing. However cervical esophagus, gastro-esophageal junction, stomach and right colonic lesions may be better for clip therapy rather than stenting. Recent developments in this field include use of endovac therapy which consists of a sponge with suction device, biodegradable stent, use of fibrin glue and some endo-suturing device. Conservative therapy with no surgical or endoscopic intervention, may be suitable for a small subset of patients. An algorithm based on location, size of defect, associated stricture, infection and available expertise needs to be developed to reduce the mortality and morbidity of this difficult clinical problem.

Conservative management for iatrogenic gastric perforation by transesophageal echocardiography

“…The surgical management of gastrointestinal tract perforations is now often replaced by conservative therapy [12]. For example, Merchea et al reported that non-operative management of EGD-associated upper gastrointestinal perforation can be successful when there is no evidence of contrast extravasation or free fluid on radiographic studies [13].…”

Retrospective analysis of the effects of continuous intraluminal aspiration on postoperative intestinal fistulas

“…Invasive methods are commonly used to treat fistulas and complications due to anastomotic leakage that develop after surgery for many benign and malignant GI diseases, which previously had only one treatment [5][6][7][8][9][10][11][12]. Because of the high morbidity and mortality of patients with a fistula and/or anastomotic leakage, the search for treatments has continued due to the lack of a demonstrably effective method.…”

“…Today, surgery is still used, but less frequently due to developments in endoscopic technology and assistant's tools. The success of treatments methods that are less invasive and easier than surgery has increased, and reduced complications from these methods have decreased the requirement for surgery remarkably in recent years [5][6][7][8][9][10][11][12]. In this study, we share our experience of patients who received continuous intraluminal aspiration to treat a fistula and anastomotic leakage.…”

“…Stents or clips, band ligation, and injection of tissue adhesive agents have become popular methods to treat fistulas and an anastomotic leakage [5][6][7][8][9][10][11][12]. Several methods of nonsurgical fistula closure have been attempted but none has been proved in a randomized, prospective trial.…”

Endoscopic management of esophageal perforation caused by calibrating bougie during laparoscopic sleeve gastrectomy

“…Hence, admission in an intensive care unit with resuscitation facilities, such as emergency airway equipment and respiratory support should be considered for such patients. [12] Surgical treatment is an important option in many cases, but a non-operative approach should be preferred whenever the clinical situation permits a less invasive approach. [13] Non-operative approaches include endoclipping or endoscopic stenting.…”