Endoscopic Fistulotomy Research Articles

Endoscopic Fistulotomy (through the Scope and Freehand) as a Salvage Procedure for Recurrent Perianal Fistula with Abscess Postsurgery in Crohn's Disease

Endoscopic Fistulotomy (through the Scope and Freehand) as a Salvage Procedure for Recurrent Perianal Fistula with Abscess Postsurgery in Crohn's Disease

Interventional endoscopy in inflammatory bowel disease: a comprehensive review.

Interventional endoscopy can play a key role in the multidisciplinary management of complex inflammatory bowel disease (IBD) as an adjunct to medical and surgical therapy. The primary role of interventional IBD (IIBD) includes the treatment of Crohn's disease-related stricture, fistula, and abscess. Endoscopic balloon dilation (EBD), endoscopic stricturotomy, and placement of endoscopic stents are different forms of endoscopic stricture therapy. EBD is the most widely used therapy whereas endoscopic stricturotomy has higher long-term efficacy than EBD. Fully covered and partially covered self-expanding metal stents are useful in long and refractory strictures whereas lumen-apposing metal stents can be used in short, and anastomotic strictures. Endoscopic fistula/abscess therapy includes endoscopic fistulotomy, seton placement, endoscopic ultrasound-guided drainage of rectal/pelvic abscess, and endoscopic injection of filling agents (fistula plug/glue/stem cell). Endoscopic seton placement and fistulotomy are mainly feasible in short, superficial, single tract fistula and in those with prior surgical seton placement. Similarly, endoscopic fistulotomy is usually feasible in short, superficial, single-tract fistula. Endoscopic closure therapies like over-the-scope clips, suturing, and self-expanding metal stent should be avoided for de novo/bowel to hollow organ fistulas. Other indications include management of postoperative complications in IBD such as management of surgical leaks and complications of pouchitis in ulcerative colitis. Additional indications include endoscopic resection of ulcerative colitis-associated neoplasia (by endoscopic mucosal resection, endoscopic submucosal dissection, and endoscopic full-thickness resection), retrieval of retained capsule endoscope, and control of bleeding. IIBD therapies can potentially act as a bridge between medical and surgical therapy for properly selected IBD patients.

916 Endoscopic Fistulotomy vs. Redo Surgery for the Treatment of Pouch-to-Pouch Fistula in Patients With Inflammatory Bowel Disease

INTRODUCTION: Pouch-to-pouch fistula is a rare yet challenging complication in patients who underwent ileal pouch-anal anastomosis. The aim of this study was to compare endoscopic fistulotomy and redo pouch surgery in the management of pouch-to-pouch fistula. METHODS: All consecutive patients with pouch-to-pouch sinuses treated with endoscopic fistulotomy vs. redo surgery from 2000 to 2018 were identified. The primary outcomes were surgery-free survivals and post-procedural complications. RESULTS: This historical cohort study included a total of 59 patients (endoscopic fistulotomy, N = 40 and redo surgery, N = 19). Complete resolution of the fistula was achieved in 29/37 (78.4%) patients, partial healing was seen in 8/37 (21.6%) patients with endoscopic fistulotomy while an initial complete healing was obtained in all patients receiving redo surgery. During a foolow-up of 1.4 years, subsequent surgery was needed in 4 (10.0%) patients with endoscopic fistulotomy and 4 (21.1%) patients with initial redo surgery (P = 0.45). Kaplan-Meier surgery-free survivals after initial procedure showed no statistical difference between the two groups (P = 0.42). The rate of adverse events in the endoscopic fistulotomy group was significantly lower than that in the surgery group (5.6% vs. 68.4%, P < 0.001). Patients receiving redo surgery had complications of a higher Clavien-Dindo class as well. CONCLUSION: Surgery-free survival were comparable between patients treated with endoscopic fistulotomy and redo surgery, while pouch redo surgery was found to be associated with a higher immediate complete healing rate yet a higher morbidity.

Recent trends (2016-2017) in the treatment of inflammatory bowel disease.

Prevalence of inflammatory bowel disease (IBD), ulcerative colitis and Crohn's disease has dramatically increased in Asian countries in the last three decades. In this period, many new medical therapies were introduced for the treatment of IBD, such as immunosuppressants, anti‐tumor necrosis factor agents, leukocyte apheresis, anti‐integrin antibody, and so on, which have contributed to induce remission and to reduce complications in IBD. As for surgical techniques for Crohn's disease, a stapled functional end‐to‐end anastomosis and conventional end‐to‐end anastomosis have similar perianastomotic recurrence rate and reoperation rate. Prospective randomized controlled studies which compare Kono‐S anastomosis and stapled side‐to‐side anastomosis are ongoing. Variant two‐stage ileal pouch anal anastomosis (IPAA) and transanal IPAA are new concepts for surgical treatment of ulcerative colitis. Various endoscopic procedures, such as balloon dilation for stenosis or stricture, endoscopic fistulotomy, injection of filling agents, and clipping for fistulas or perforations will be new options in the treatment of Crohn's disease. Adverse effects of preoperative treatments on postoperative complications should also be taken into account to improve surgical outcomes in IBD patients.

Endoscopic fistulotomy in inflammatory bowel disease (with video)

Fistulas in patients with inflammatory bowel disease (IBD) pose a key challenge in the management of these patients. We aimed to describe a novel endoscopic method to treat patients with IBD who have fistulas. A cohort of 29 consecutive patients with fistulas and IBD were identified in the registry of our interventional IBD unit. An endoscopic fistulotomy with needle-knife was performed. The primary outcome was healing of the fistula without the need for surgical intervention. A total of 29 patients underwent endoscopic fistulotomy; and the mean (± standard deviation) age of patients undergoing the procedure was 44.2 ± 14.6 years. Thirteen patients were male (44.8%), and 16 were female (55.2%). Twenty-six patients (89.6%) achieved complete resolution of the fistula as confirmed by endoscopy with a guidewire and/or cross-sectional abdominal imaging, with 10 patients (34.4%) requiring a single endoscopic treatment session. Three patients (10.3%) had a persistent fistula and required surgical intervention. One patient had postoperative bleeding requiring blood transfusion and hospitalization. Endoscopic fistulotomy with a needle-knife appears to be safe and effective in treating IBD-related fistulas.

Biliary drainage by endoscopic choledochoduodenal fistulotomy in patients with papillary carcinoma

Background: There are few reports of endoscopic choledochoduodenal fistulotomy (endoscopic fistulotomy) in patients with papillary carcinoma by using a needle-knife. Methods: Among 35 patients with papillary carcinoma requiring biliary drainage, 14 with a suprapapillary bulge underwent endoscopic fistulotomy alone or with widening of the fistula by using a standard sphincterotome or dilation balloon catheter. Observations: Transfistula bile duct cannulation was successful on the first attempt in 13 of 14 patients (93%) and temporary biliary drainage through the fistula was successfully established in all 13 patients. The single complication was minor bleeding (7%) in 1 patient. In 6 patients with biliary obstruction who were not operative candidates, endoscopic fistulotomy was used for palliation, and all remained asymptomatic for a mean period of 3.2 months. Conclusions: Endoscopic fistulotomy is an effective, relatively safe biliary drainage procedure. It should be considered in selected patients with bile duct obstruction caused by papillary carcinoma and a suprapapillary bulge caused by the dilated bile duct.

3395 Clinical usefulness of primary endoscopic choledochoduodenal fistulotomy in patients with ampullary cancer.

Background: In patients with ampullary cancer, the use of endoscopic choledochoduodenal fistulotomy (endoscopic fistulotomy) between the bulged suprapapillary intraduodenal part of the bile duct and the duodenum by needle-knife sphincterotome (NKS) has been reported sporadically as an alternative to failed bile duct cannulation and subsequent endocopic biliary drainage such as biliary stenting or endoscopic sphincterotomy (EST). However, endoscopic fistulotomy can be performed primarily, for both successful biliary drainage and avoidance of recurrent symptoms by possible stent dysfunction or fatal bleeding by EST, in patients especially with suprapapillary bulged, distorted, or friable to bleeding papilla causing failed endoscopic biliary drainage procedures. Aim: To evaluate safety and clinical usefulness of primary endoscopic fistulotomy in patients with ampullary cancer. Methods: Of the 29 patients with ampullary cancer requiring biliary drainage, 13 patients(44.8%) with suprapapillary bulged papilla underwent fistulotomy using NKS (HPC-2, Wilson-Cook Medical Co, NC) alone or followed by upward extension of the fistulous orifice using standard sphincterotome (fistulotomy group). The remaining 16 patients underwent transpapillary stenting with standard techniques (transpapillary stenting group). In both groups, the success rate of bile duct cannulation and effective biliary drainage was assessed and compared. Results: Bile duct cannulation was successful in 12 patients (92.3%) of the fistulotomy group and 13 patients (81.3%) of the transpapillary stenting group (p>0.05), and complication was mild bleeding in 1 patient (7.7%) and cholangitis by stent occlusion in 1 patient (6.3%), respectively (p>0.05). The success rate of initial biliary drainage by endoscopic fistulotomy and transpapillary stenting was 100% and 84.6% (p>0.05), respectively. In 13 patients, biliary drainage was used as a definite treatment and the symptom-free duration was 3.2 months in 7 patients (52.8%)of the fistulotomy group and 3.9 months in 6 patients (37.5%) of the transpapillary stenting group (p>0.05). Conclusions: Endoscopic fistulotomy is as effective as transpapillary stenting in preoperative or palliative decompression of the obstructed bile duct due to the ampullary cancer. Without the need of biliary stenting, this can be employed primarily with safety in selective patitients when bulged suprapapillary intraduodenal part of the bile duct is observed definitely.

Endoscopic Fistulotomy – ‘The Suprapapillary Punch’: A Method of Access to the Bile Duct during ERCP

Endoscopic retrograde cholangiopancreatography (ERCP) is established as the method of choice to investigate the biliary tree when obstruction is suspected. On rare occasions, the papilla cannot be entered because of anatomical or pathological abnormalities. This report describes endoscopic fistulotomy or the suprapapillary punch that has been carried out at the Foothills Hospital in Calgary, Alberta, on 30 of 623 patients referred for ERCP for conditions causing obstruction of the common bile duct or suspected obstruction of the common bile duct. The following communication also describes the method of suprapapillary punch or endoscopic fistulotomy. Results have been excellent with only one complication, a minor attack of pancreatitis after the procedure. In summary, the suprapapillary punch or fistulotomy is a safe and useful method for entering the common bile duct when access by the usual method is impossible.

Endoscopic fistulotomy and biliary drainage as the ultimate palliative treatment for obstruction due to malignant tumors of the papilla of Vater

This report describes the technique and results of endoscopic fistulotomy as a drainage procedure in cases of malignant obstruction of the biliary system from bulky and friable growths in the papilla of Vater. Fistulotomy, coupled with insertion of stents, was successful in seven of eight patients and was associated with relief of jaundice. It is suggested that the method be applied when conventional transpapillary insertion of stents is impossible either due to distortion of the papilla or bleeding of the growth on touch.