Mo1535 Outcomes of Fistula Closure by Endoscopic Suturing: a Multi- Center Study

Abstract

Mo1534 Extreme Endoscopy: a New Paradigm in Interventional Endoscopy Monkemuller Klaus*, Paul T. Kroner, Mark C. Phillips, Helmut Neumann, Ivan Jovanovic Basil I. Hirschowitz Endoscopic Center of Excellence, University of Alabama, Birmingham, AL Introduction: Extreme endoscopy is a new discipline in interventional GI endoscopy. Previous data on extreme endoscopy comes from case reports. Aims: To report on the feasibility and outcomes of extreme endoscopy. Methods: Observational, retrospective study conducted at a tertiary care hospital during an 18-months period. All procedures were performed under general anesthesia. Extreme endoscopy comprises five key components: (i) use of multiple scopes or dual endoscope technique; (ii) use of various types of overtubes (OT), (iii) utilization of modified devices, (iv) use of fluoroscopy and, (v) necessity of utilizing a tool box with: wire cutter, glue, tape, foam (Endosponge). Singleor double balloon enteroscopy (SBE, DBE) was not defined as extreme endoscopy, unless the technique was utilized to perform a) endoscopic re-anastomosis of disrupted GI tract; b) PATENT (percutaneous assisted transprosthetic endoscopic therapy); c) SBEor DBE-rendezvousERCP; d) endoluminal stenting, e) removal of migrated SEMS from the small bowel. Additional exclusions: ESD or POEM cases (nZ45) and pancreatic necrosectomies (nZ28). Success was defined as resolution of the primary luminal problem. Results: 44 patients (23 females, 21 males, mean age 57 years, age range 32-83) with various types of complex primary, secondary or post-surgical anatomy endoluminal GI defects were studied. In 20 patients (45%) previous surgical, endoscopic or radiologic attempts at solving the problem had failed. In 11 patients (25%) there were no other interventional treatment options available. Interventions performed: PATENT (nZ3), endoscopic re-anastomosis of the disrupted GI tract (nZ4), Endosponge placement for drainage of huge cavities (nZ3), OT-assisted removal of mesh (nZ2), OT-assisted removal of migrated lap bands (nZ3), OT-assisted SEMS placement of the small bowel and/or colon (nZ8), combined closure of fistula or perforation and placement of direct endoscopic jejunostomy (nZ7), SBEor DBE ERCP with exchange of scope for slim cholangioscope to perform EHL (nZ4), rendezvous-DBE ERCP to place SEMS into the bile duct (nZ3) or to place plastic stents percutaneously under direct endoscopic view (nZ2), OT-assisted endoscopy allowing for ERCP or PEG placement in patients with esophageal stenosis (nZ3). The technical success was 87.8%. The mean procedure time was 35 minutes (range 45 min to 4 hours). There were no major adverse events associated with the procedures. Conclusions: This is the largest study reporting on extreme endoscopy. Albeit time consuming extreme endoscopic interventions lead to a resolution or remediation of complex endoluminal disorders in the majority of patients. It appears that extreme endoscopy may provide hope for patients in whom no other choices exist. Now multi-center studies in this topic are warranted. Mo1535 Outcomes of Fistula Closure by Endoscopic Suturing: a MultiCenter Study Saurabh S. Mukewar*, Nitin Kumar, Marc F. Catalano, Christopher C. Thompson, Christopher J. Gostout Gastroenterology, Mayo Clinic, Rochester, MN; Gastroenterology, Brigham and Women’s hospital, Boston, MA; Gastroenterology, GI Health Associates, Milwaukee, WI Background: Endoscopic closure of fistulas is desirable but remains a challenge, especially for gastrogastric fistulas. We report a multicenter experience using endoscopic suturing to close gastrointestinal fistulas. Methods: Electronic records at two academic centers and one private clinic were reviewed to identify patients who underwent sutured fistula closure (OverStitch, Apollo Endosurgery , Inc., Austin, Texas). Demographic, clinical variables and details of endoscopic procedure were recorded. Results: A total of 56 patients underwent single session fistula closure (26: Brigham and Women’s hospital; 21: Mayo Clinic and 9: GI associates, Milwaukee, WI). Mean age was 54 +/12.7 years. Gastrogastric fistula (29 (51.8%) was the most common fistula. 16 (28.6%) had a failed previous attempt at closure of fistula. Immediate success was seen in all cases [56 (100%)] and 17 (42.5%) had successful closure of fistulas as observed on endoscopy [18(45%)], imaging [13(32.5%)] or clinical [5(12.5%)] follow up. Gastrogastric fistulas had lower rates of closure [5/19 (26.3%)] compared to other fistulas [12/21 (57.1%)]. Data on subsequent procedures and outcomes was available from Mayo cohort. Out of 21 patients, 2 underwent surgery, 3 had no follow up imaging/endoscopy. 9/15 (60%) required repeat endoscopic procedures (range: 1 to 4) with successful outcome in 4/9 (44.5%) cases. Only one patient (1.8%) had abdominal pain requiring hospital admission. Conclusion: Single session suture closures of fistulas alone are safe and can be effective especially in known challenging cases. Sequential closures for persistent fistula warrants attention. Age* 53.9 +/Type of fistula Fistula sutures^ 2