Endoscopic submucosal dissection combined with clip for closure of gastrointestinal fistulas including those refractory to previous therapy

Abstract

Background Gastrointestinal (GI) fistula is a life-threatening condition and a therapeutic challenge. Endoscopic approaches include mucosal abrasion, clip closure, or stent diversion, with moderate success rates in the long term. We assessed whether fistula endoscopic submucosal dissection with clip closure (FESDC) could lead to complete resolution of fistulas even after failure of previous endoscopic therapy.

Methods Patients with GI fistulas, including those with previous failed treatment, were retrospectively included. The primary outcome was long-term (> 3 months) success of fistula healing. Secondary outcomes included technical success, safety, and factors associated with FESDC success.

Results 23 patients (13 refractory 57 %) were included. Tight immediate sealing was achieved in 19 patients (83 %; 95 % confidence interval [CI] 61 %–95 %). Long-term closure was achieved in 14 patients (61 %; 95 %CI 39 %–80 %), with median follow-up of 20 months. Complications occurred in two patients (9 %). Previous local malignancy (P = 0.08) and radiotherapy (P = 0.047) were associated with a higher risk of failure.

Conclusion This novel FESDC strategy was demonstrated to be safe and feasible for permanent endoscopic closure of GI fistulas. Further studies are warranted to determine the place of this technique in the management of chronic GI fistula.

• References

• 1 Willingham FF, Buscaglia JM. Endoscopic management of gastrointestinal leaks and fistulae. Clin Gastroenterol Hepatol 2015; 13: 1714-1721
• 2 Silon B, Siddiqui AA, Taylor LJ. et al. Endoscopic management of esophagorespiratory fistulas: a multicenter retrospective study of techniques and outcomes. Dig Dis Sci 2017; 62: 424-431
• 3 El Hajj II, Imperiale TF, Rex DK. et al. Treatment of esophageal leaks, fistulae, and perforations with temporary stents: evaluation of efficacy, adverse events, and factors associated with successful outcomes. Gastrointest Endosc 2014; 79: 589-598
• 4 Gonzalez J-M, Servajean C, Aider B. et al. Efficacy of the endoscopic management of postoperative fistulas of leakages after esophageal surgery for cancer: a retrospective series. Surg Endosc 2016; 30: 4895-4903
• 5 Shehab HM, Hakky SM, Gawdat KA. An endoscopic strategy combining mega stents and over-the-scope clips for the management of post-bariatric surgery leaks and fistulas (with video). Obes Surg 2016; 26: 941-948
• 6 Shehab H, Abdallah E, Gawdat K. et al. Large bariatric-specific stents and over-the-scope clips in the management of post-bariatric surgery leaks. Obes Surg 2018; 28: 15-24
• 7 Nagami Y, Ominami M, Sakai T. et al. Endoscopic closure of refractory esophageal fistula after esophagectomy using polyglycolic acid sheets: a pilot study. Endosc Int Open 2020; 8: E591-E595
• 8 Shin JH, Song H-Y, Ko G-Y. et al. Esophagorespiratory fistula: long-term results of palliative treatment with covered expandable metallic stents in 61 patients. Radiology 2004; 232: 252-259
• 9 Debourdeau A, Gonzalez J-M, Dutau H. et al. Endoscopic treatment of nonmalignant tracheoesophageal and bronchoesophageal fistula: results and prognostic factors for its success. Surg Endosc 2019; 33: 549-556
• 10 Gruner M, Heissat S, Pitiot V. et al. Successful endoscopic closure of a refractory button-battery tracheoesophageal fistula in a 3-year child using endoscopic submucosal dissection of the surrounding mucosa. Endoscopy 2017; 49: E212-E214
• 11 Bertrand G, Jacques J, Rivory J. et al. Deep endoscopic submucosal dissection of a refractory tracheoesophageal fistula using clip-and-line traction: a successful closure. Endoscopy 2017; 49: 1278-1280
• 12 Barsic N, Rivory J, Monneuse O. et al. Successful closure of a refractory rectal anastomotic fistula using endoscopic submucosal dissection combined with an over-the-scope clip. Endoscopy 2018; 50: E99-E101
• 13 Gay-Chevallier S, Lupu A, Rivory J. et al. Closure of non-healing gastrocutaneous fistula after percutaneous endoscopic gastrostomy by endoscopic submucosal dissection and over-the-scope clip. Endoscopy 2019; 51: E125-E126
• 14 Wallenhorst T, Jacques J, Bouguen G. et al. Successful closure of a rectal fistula of Crohn’s disease using endoscopic submucosal dissection combined with an over-the-scope clip. Am J Gastroenterol 2019; 114: 1416
• 15 Ciochina M, Cruceru M, Rivory J. et al. Esophagobronchial fistula after sleeve gastrectomy successfully treated by endoscopic submucosal dissection and over-the-scope clip. Endoscopy 2020; 52: E100-E101
• 16 Jacques J, Charissoux A, Bordillon P. et al. High proficiency of colonic endoscopic submucosal dissection in Europe thanks to countertraction strategy using a double clip and rubber band. Endosc Int Open 2019; 7: E1166-E1174
• 17 Donatelli G, Spota A, Cereatti F. et al. Endoscopic internal drainage for the management of leak, fistula, and collection after sleeve gastrectomy: our experience in 617 consecutive patients. Surg Obes Relat Dis 2021; 17: 1432-1439
• 18 Rogalski P, Swidnicka-Siergiejko A, Wasielica-Berger J. et al. Endoscopic management of leaks and fistulas after bariatric surgery: a systematic review and meta-analysis. Surg Endosc 2021; 35: 1067-1087
• 19 Aynaci E, Kocatürk CI, Yildiz P. et al. Argon plasma coagulation as an alternative treatment for bronchopleural fistulas developed after sleeve pneumonectomy. Interact Cardiovasc Thorac Surg 2012; 14: 912-914
• 20 Mizuta H, Nishimori I, Kuratani Y. et al. Predictive factors for esophageal stenosis after endoscopic submucosal dissection for superficial esophageal cancer. Dis Esophagus 2009; 22: 626-631
• 21 Pimentel-Nunes P, Dinis-Ribeiro M, Ponchon T. et al. Endoscopic submucosal dissection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2015; 47: 829-854