Usefulness of over-the-scope clipping system for closing digestive fistulas

Abstract

Background and aim: Therapeutic endoscopy has recently evolved into the treatment of complex gastrointestinal (GI) postoperative leakage, especially with over-the-scope clips (OTSC). We describe our 2-year experience of 30 patients treated for digestive fistulas using the OTSC device.

Methods: This was a retrospective study conducted on patients referred for GI fistulas in two French hospitals. Technical aspects, clinical outcomes and closure rates were recorded.

Results: Thirty patients were treated for GI leaks: 19 (63%) had a gastric fistula after laparoscopic sleeve gastrectomy (LSG); the others had rectovaginal, urethrorectal, rectovesical, gastrogastric, gastrocutaneous, esophagojejunal fistulas and colorectal anastomotic leak. Average follow up was 10.4 months. Eighteen (60%) had undergone previous endoscopic or surgical treatment. Orifice size was 3-20 mm (average 7.2 mm). Successful OTSC placement was achieved in 30 out of 34 attempts. There were four intraoperative undesired events (13.3%) but these were successfully managed. Overall success rate was 71.4% and 16 patients (53%) recovered with primary efficacy. Six patients (20%) required a subsequent endoscopic treatment. Eight patients (26.7%) required surgery for failure. In nine cases, we used one or more additional endoscopic procedures concomitantly with the OTSC combining self-expandable metal stents, standard clips and glue injection. Healing rate after LSG fistula was 88.9%, which was significantly higher than the overall rate (P = 0.01).

Conclusion: OTSC placement seems to be safe and effective for the treatment of GI fistulas. Better results were seen in leaks after LSG.

Keywords: bariatric surgery; digestive fistula; over-the-scope clip (OTSC) system; postoperative complication; therapeutic endoscopy.