Endoscopic management of gastrointestinal perforations, leaks and fistulas

Abstract

Gastrointestinal perforations, leaks and fistulas may be serious and life-threatening. The increasing number of endoscopic procedures with a high risk of perforation and the increasing incidence of leakage associated with bariatric operations call for a minimally invasive treatment for these complications. The therapeutic approach can vary greatly depending on the size, location, and timing of gastrointestinal wall defect recognition. Some asymptomatic patients can be treated conservatively, while patients with septic symptoms or cardio-pulmonary insufficiency may require intensive care and urgent surgical treatment. However, most gastrointestinal wall defects can be satisfactorily treated by endoscopy. Although the initial endoscopic closure rates of chronic fistulas is very high, the long-term results of these treatments remain a clinical problem. The efficacy of endoscopic therapy depends on several factors and the best mode of treatment will depend on a precise localization of the site, the extent of the leak and the endoscopic appearance of the lesion. Many endoscopic tools for effective closure of gastrointestinal wall defects are currently available. In this review, we summarized the basic principles of the management of acute iatrogenic perforations, as well as of postoperative leaks and chronic fistulas of the gastrointestinal tract. We also described the effectiveness of various endoscopic methods based on current research and our experience.

Keywords: Clips; Endoscopic; Fistula; Leak; Management; Perforation; Stent.

Figure 1

Over the scope clip closure of an esophageal perforation. A: Over the scope clip closure of the defect caused by thermal damage during cardiac surgery; B: Endoscopy showing complete closure of the defect. Taken from Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, Poland.

Figure 2

Boerhaave syndrome. A: Computed tomography scan showing the presence of air in the mediastinum; B: Over the scope clip closure of the perforation and feeding tube placement. Taken from Department of Gastroenterology and Internal Medicine, Medical University of Bialystok, Poland.