Tu1023 EFFICACY OF POLYGLYCOLIC ACID SHEETING WITH FIBRIN GLUE FOR GASTROINTESTINAL FISTULAS: A MULTICENTER RETROSPECTIVE STUDY

Abstract

Anastomotic leakage, which is one of the complications of surgical operations, chemoradiation therapies (CRT) sometimes causes a refractory fistula despite conservative therapy, including local drainage and decompression of the digestive tract. Polyglycolic acid (PGA) sheets (Neoveil; Gunze, Kyoto, Japan) with fibrin glue (Beriplast P Combi-Set; CSL Behring Pharma, Tokyo, Japan) can be useful for closure of gastrointestinal fistulas, large-scale multicenter treatment outcomes have not been reported. Patients with GI fistulas endoscopically closed using PGA sheeting with fibrin glue between April 2013 and March 2018 in 18 institutions in the PGA study group, which is the affiliated study group of the Japanese Gastroenterological Endoscopy Society, were identifiedand retrospectively analyzed. Fistula is defined as the communication between the digestive tract and other areas (thoracic cavity, mediastinum, bronchus, abdominal cavity, etc.). Fistulas were filled with one or several pieces of PGA sheets followed by spraying fibrin glue using an endoscopic catheter. The procedure was repeated several times at 1- or 4-week intervals before fistula closure, and accompanied by nasal or percutaneous drainages, and endoscopic clipping as appropriate for each case. Fistula: Forty-five cases (hypopharyngeal/esophageal cancer 23, gastric cancer 5, colon cancer 4, and communicating organs: chest cavity 5, mediastinum 4, bronchus/lung 10/4, abdominal cavity 6, retroperitoneum 2, and others 14) were extracted. The median fistula diameter was 5 mm (range 1–20 mm). Thirty-six cases were related with operations; and 9, with other conditions, including CRT. PGA sheets were filled at a median of 2 times (range 1–10). Infections caused by fistulas were suspected in 12 cases (22%) because pus was observed in the fistulas. Percutaneous drainage was performed in 26 cases (58%); nasal drainage, in 14 (31%); and endoscopic clipping, in 16 (36%). Complete closure was attained in 25 cases (56%). The median period until resuming diet after starting sheeting was 16 days (range 1–222 days) in the closed cases. No statistically significant differences in fistula size, performance status, accompanying drainage, and the period between fistula occurrence and start of sheeting and fistula closure. The leak connected to bronchus/lung was significantly difficult to close compared with fistulas connected without bronchus (p=0.01). No statistically significant difference was observed in Albumin level (≧3.8, <3.8), but it was marginal factor for fistula closure (p=0.1). Eleven deaths occurred, which were not related to PGA sheeting adverse events. Endoscopic PGA sheeting can be expected to achieve conservative closure and inhibit highly invasive reoperation for more than half of fistula cases.Eventually the fistula was closed. The meal started on the 41st day after endoscopic PGA sheet filling was started.View Large Image Figure ViewerDownload Hi-res image Download (PPT)