Endoscopic Application of Transnasal Tube, Clipping Over-The-Scope Clip, and Stenting for an Esophago-Mediastinal Fistula and Anastomotic Leakage

Abstract

Introduction: The fistula and anastomotic leakage following surgery of the upper GI tract are major causes of morbidity and mortality. The effects on the patient are wide ranging-pain, complex wound care, reduced quality of life, prolonged hospital stay and psychological effects. Complications such as malnutrition, abscesses and sepsis may occur. We report several endoscopic techniques appear to be an effective, technically feasible, and minimally invasive treatment option, and can shorten the time of closure. Methods: Twelve patients are applied following endoscopic methods. 1. Thoracic drainage inserted through trans-nasal route. Trans-nasal drainage tube through a guide wire is inserted at the site of intrathoracic esophagogastric anastomotic leak under the endoscopic observation. 2. Endoscopic management of anastomotic leakage using clipping. - The metallic clip fixing device with a loaded clip can be passed through the forceps channel of a standard endoscope. - Pulling on the handle of the fixing device leads to opening of the prongs. - Through manipulation of the tip of the endoscope the clip can be brought into position to grasp the tissue flanks of the leakage after suction to reduce the size of the fistula. 3. Endoscopic over-the-scope (OTS) clip placement. - 1. Endoscopic deployment for fistula closure by approximating the margins of the fistula opening with a single clip device. 2. Place the fistula opening at the center of the endoscopic cap, apply firm suction through the endoscopic channel allowing the surrounding tissues to be suctioned into the endoscopic cap attachment. 3. Deploy the clipping device by turning the firing wheel attached to the endoscope handle. 4. Endoscopic stenting. - 1. At first we confirm the location of the fistula or leakage by endoscopy and X-ray contrast. - 2. The removable covered stent in the setting of anastomotic leak or fistel is used in sealing the leak or fistel. Results: 1. We succeeded to close the fistula and anastomotic leakage of all cases by endoscopic procedures. 2. In a case the stent was migrated but the fistula was closed. Conclusion: There is encouraging progress in shortening the time to closure of the leakage and reducing the risk of severe systemic complications such as sepsis or malnutrition and an apparent reduction of global costs, with a broad range of conservative and endoscopic therapeutic methods.