Sp601 Endoscopic Placement of a Polyglactin Patch Secured with Hemoclips for the Treatment of Difficult Surgical Fistulas: Initial Experience in 3 Cases

Abstract

Chronic surgical fistulas have proven extremely difficult to close by surgical, radiologic or endoscopic means. Many new techniques and devices have recently been introduced. We proposed that a bulky patch would be more effective in plugging a GI fistula if it could be fixed adequately into its internal opening. We chose polyglactin mesh due to its wide use in surgical wound care, its high strength with slow reabsorption and its low cost. The patches are prepared with silk suture loops for attachment and are custom matched to the fistula openings. We present 3 chronic fistulas that defied prior efforts at closure which we were successful in closing using a technique not previously reported. Three cases with post-operative fistulas with previous attempts at endoscopic closure were referred. Cases included a duodeno-cutaneous, jejunocutaneous and esophagobronchial fistula after ulcer, Whipple and esophageal surgery. Closure was accomplished endoscopically using a physician prepared polyglactin absorbable patch. After APC mucosal ablation, the patches were pressed into the fistulas from within the GI tract and multiple clips were used to fix them in place. A temporary coated esophageal stent was used in the esophageal case to hold the patch in place. All were successful in effecting immediate closure. Cases are presented in increasing order of dificulty. No complications or untoward events occurred. Clinical polyglactin patch placement appears to be an, inexpensive endoscopic procedure using readily available surgical materials. This new procedure ads to the endoscopist's arsenal of techniques in dealing with GI fistulas following surgery. Comparative trials to other newly described endoscopic techniques are warranted.