CLOSURE OF GASTROINTESTINAL FISTULAS WITH ENDOCLIPS-EVIDENCE BASED MEDICINE REVIEW OF LITERATURE

Abstract

Purpose: Although a number of randomized controlled trials are available demonstrating the efficacy of endoclip application in the management of gastrointestinal bleeding, information on the role of endoclips in treating gastrointestinal perforations is limited. The aim of this study is to present an evidence based medicine (EBM) review of literature on the role of endoclips in the management of gastrointestinal perforations, fistulas, and leaks. Methods: A MEDLINE search of English language publications was performed from 1966 to June of 2003 related to endoclipping by using the keywords “endoclip” or “hemoclip.” An overall quality assessment of the available publications was done according to EBM. Results: First Report: Binmoeller et al reported successful endoscopic closure of a gastric perforation using metallic clips after snare excision of a gastric leiomyoma in 1993. Case Reports: 38 cases of gastrointestinal perforations, fistulas, and anastamotic leaks treated by the endoscopists with endoclips without a need for laparotomy have been published in peer-reviewed journals. Randomized Controlled Trials: None. Closure of Perforations, Fistulas, and Leaks: The endoclips were successful in the closure of perforations, fistulas, and leaks of the esophagus, stomach, duodenum, and colon. a. Esophageal Perforations: Endoclipping was successful in the closure of esophageal perforations resulting from endoscopy, bougeinage of esophageal stricture, balloon dilation of anastomotic strictures, pneumatic balloon dilation of achalasia, fish bone ingestion, metal hook ingestion, Mallory-Weiss tear, Boerhaave's syndrome, and empyema. b. Gastroduodenal perforations resulting from endoscopic ultrasound examination, snare polypectomy of gastric tumors, endoscopic mucosal resection of early gastric cancer, biliary sphincterotomy, ampullectomy, and biliary stent migration have been successfully closed by endoclipping. c. Colonic perforations from colonoscopy and endoscopic mucosal resection of colonic neoplasia, colo-cutaneous fistulas following a PEG placement and rupture of periappendicial abscess, and colo-vesical fistula from diver-ticulitis have been successfully closed with endoclips. Nature of Defect Closed: Fresh perforation to a chronic fistula of 2 to 3 months and defect of 0.5 cm to 2.5 cm. Details of each case report will be presented in a tabular form for the poster. Evidence for endoclip closure of gastrointestinal fistulas: Grade B. Conclusions: Endoclips are useful in the closure of perforations, fistulas, and anastomotic leaks.