Minimally invasive treatment of postoperative fistulas, leakages, and perforations of the upper gastrointestinal tract: a single-center observational study

Abstract

Introduction: Most anastomotic leaks in the upper gastrointestinal (GI) tract can be treated with minimally invasive techniques dominated by endoluminal vacuum therapy (EVT) or stent implantation. Chronic leaks often require additional solutions, such as tissue adhesives or cellular growth stimulants.

Aim: To present a treatment strategy for postoperative leakage of upper GI anastomoses with noninvasive procedures.

Material and methods: A group of 19 patients treated in the period 2015-2023 with postoperative upper GI tract leakage was enrolled for endoscopic treatment. The indication for the therapy was anastomotic dehiscence not exceeding half of the circumference and the absence of severe septic complications. All patients were managed using endoscopic vacuum therapy (EVT) or a self-expanding stent while persistent fistulas were additionally treated with alternative methods.

Results: The EVT was successfully implemented in 13 cases, but 7 patients required alternative methods to achieve definitive healing. Self-expanding stent placement was performed in 6 patients; however, in 3 cases a periprosthetic leakage occurred. In this group, 2 patients had the stent removed and the third one died due to septic complications. Post-treatment stenosis was identified in 5 patients after EVT that required balloon dilation with acceptable resolution in all cases.

Conclusions: Early detected anastomotic dehiscence limited to half of the circumference most effectively responded to the noninvasive treatment. Nutritional support as well as complementary endoscopic solutions such as tissue adhesives, growth stimulants and hemostatic clips increase the percentage of complete healing.

Keywords: anastomotic dehiscence; endoscopic stent implementation; endoscopic vacuum therapy; noninvasive leak treatment.

Photo 1

Endoscopic assessment of the size of the leakage in order to create a vacuum dressing. The arrow (⇨) marks the fistula channel

Photo 2

The next steps of preparing the EVT dressing

Photo 3

Positioning the dressing into the lumen of the fistula using endoscopic forceps

Photo 4

Intraluminal dressing as an alternative solution when it is not possible to use a direct EVT. The white arrow marks the feeding catheter, the black arrow the drain of the EVT dressing

Photo 5

A guide wire with a hydrophilic tip supports the insertion of the dressing in places difficult to penetrate with the endoscope

Photo 6

Closure of residual fistula with fibrin glue. The ERCP catheter is used as a sealant applicator (A), then the edges of the fistula are closed with a hemostatic clip (B)

Figure 1

Summary of treatment results depending on the non-invasive approach

Figure 2

The final results depend on the strategy of non-invasive treatment

Figure 3

Effectiveness of leakage resorption depending on the start of treatment