Gastrointestinal Fistulas Research Articles

Endoscopic vacuum therapy versus endoscopic stenting for upper gastrointestinal transmural defects: Systematic review and meta-analysis.

Upper gastrointestinal fistulas, leaks, and perforations represent a high cost burden to health systems worldwide, with high morbidity and mortality rates for affected patients. Management of these transmural defects remains therapeutically challenging. The aim of this study is to perform a systematic review and meta-analysis to investigate the efficacy and safety of self-expanding metal stents (SEMS) versus endoscopic vacuum therapy (EVT) for treatment of upper gastrointestinal transmural defects. Searches were performed on MEDLINE, EMBASE, Central Cochrane, Latin American and Caribbean Health (LILACS), and gray literature, as well as a manual search to identify studies comparing SEMS versus EVT to treat upper gastrointestinal transmural defects. Evaluated outcomes were: rates of successful closure, mortality, length of hospital stay, duration of treatment, and adverse events. Five studies with a total of 274 patients were included. There was a 21% increase in successful fistula closure attributed to EVT compared with the SEMS group (RD 0.21, CI 0.10-0.32; P=0.0003). EVT demonstrated a 12% reduction in mortality compared to stenting (RD 0.12, CI 0.03-0.21; P=0.006) and an average reduction of 14.22days in duration of treatment (CI 8.38-20.07; P<0.00001). There was a 24% reduction in adverse events (RD 0.24, CI 0.13-0.35; P=0.0001. There were no statistical differences between the studied therapies regarding the length of hospital stay. Endoscopic vacuum therapy proves to be superior in successful defect closure, mortality, adverse events and duration of treatment.

Safety and efficacy of aflibercept in FOLFIRI regime in treatment of metastatic colorectal cancer in real clinical practice: results of Russian prospective multicentre observational study SAFETRAP

Aim. The main objective of the prospective multicentre observational study is to describe adverse events occurred during treatment with aflibercept plus FOLFIRI therapy in real life practice. In despite of broad use of aflibercept in Federal oncological centers, this regimen is still perceived by healthcare professionals (HCPs) as having worse safety profile in comparison with other antiangiogenic agents. Taking into account limited experience of using aflibercept in Russia it s critically important to evaluate and document adverse events occurred with treatment in aflibercept plus FOLFIRI regimen in patients with metastatic colorectal cancer (mCRC) in real-life practice. Methods. The physician selection was performed as a random process. Twenty sites with experience in treatment of mCRC patients were selected. The investigators were encouraged to enroll all patients meeting eligibility criteria in consecutive manner. Total number of included patients into the study patient was 101. Data were evaluable for 91 patients. 14 of 91 (15.4 %) patients didn ’t meet inclusion criteria and were excluded from the per protocol analysis: 10 patients didn ’t receive oxaliplatin within the last line of therapy preceding inclusion into the study and in 4 patients progression occurred more than 6 months after the end of adjuvant therapy. Results. Overall, 265 treatment emergent adverse events (TEAEs) occurred in the 77 patients analysed per protocol. In total, 23 grade 3 and 5 grade 4 TEAEs were reported by 16 and 4 patients, respectively. The most common TEAEs were nausea (68 events in 31 [40.3 %j patients), diarrhea (43 events in 25 [32.5 %j patients), hypertension (36 in 20 [26.0 %] patients), neutropenia (29 events in J5 [J9.5 %] patients), asthenia (28 events in 12 [15.6 %]patients). Three cases of grade 1-2 stomatitis were reported in 2 (2.6 %) patients. And one patient reported grade 1 epistaxis during the study. There was no case of gastrointestinal perforation, fistula development, ulceration, arterial or venous thromboembolism. During this study seven serious adverse events were documented in 5 (6.5 %) patients of 77. The reason for treatment discontinuation in 5 (11.1 %) of 45 cases was adverse event. No death, classified as related to any component of therapy, was reported in this study. Conclusion. This national (Russian) prospective multicentre non-interventional study conducted in patients with mCRC in daily practice suggests that aflibercept plus FOLFIRI has a manageable safety profile in line with VELOUR phase III study.

MANAGEMENT AND RESECTION OF A COLOBRONCHIAL FISTULA

SESSION TITLE: Medical Student/Resident Cardiothoracic Surgery Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: A fistula is defined as an aberrant connection between two epithelialized surfaces (1). Review of the literature finds less than 50 total case reports of colobronchial fistulas (2). Here we report a rare case of a colobronchial fistula in a 66-year-old male with foul smelling cough. CASE PRESENTATION: A 66-year-old man presented to the ED with a several month history of worsening chronic cough with foul-smelling sputum. In the time preceding the admission, the patient noted intermittent subjective fevers, chills, and night sweats. The patient had a lengthy surgical which includes a 2018 distal pancreatectomy, splenectomy, colonic resection, and partial diaphragmatic resection secondary to Gastrointestinal Stromal Tumors (GIST). Initial imaging with Chest X-ray and CT scan of the abdomen without contrast identified only a subphrenic abscess. X-ray of the colon with lower GI Gastrografin enema confirmed presence of a colobronchial fistula. During this exam, the patient began coughing up contrast and evidence of contrast in the subphrenic abscess was further confirmed on a CT. At first, the cardiothoracic surgery team recommended an initial non-surgical approach. A 10 French drainage catheter was advanced into the abscess and placed on pleurovac -40 suction. The patient was told to irrigate the cavity with 10 cc of saline 3-4 times per day with the hope the cavity would fill with granulation tissue without resection. The patient was discharged on suction and 10 days later returned with worsening cough and fevers. The fistulous connection was unchanged and the patient was taken to surgery. A muscle sparing left lower thoracotomy provided access to the fistulous communication allowing partial wedge resection of the left lower lobe and debridement of the abscess cavity. The diaphragm was partially resected and pulled away from the former fistula site. 3 Chest tubes were placed including one in the marsupialized abscess cavity and the fistula was successfully divided. DISCUSSION: Colobronchial fistulas are slow to develop and have been reported with numerous pathologic and iatrogenic processes including Crohn’s disease, colonic malignancy, diaphragmatic hernia, and postoperative adhesions (2) Identifying the fistulous tract definitively is challenging and is most commonly found by a lower GI contrast enema with X-ray which is concurrent with our case report (2). Treatment for a colobronchial fistula has always been surgical, with all cases of successful recovery requiring this intervention (2). There are no current cases describing the use of a catheter drainage in attempted marsupialization making this case unique. CONCLUSIONS: Colobronchial fistula is a rare finding that often occurs years after the initial iatrogenic or pathologic insult. It is best identified with a contrast enema imaging study and requires surgical intervention for proper treatment. Reference #1: Pickhardt PJ, Bhalla S, Balfe DM. Acquired gastrointestinal fistulas: classification, etiologies, and imaging evaluation. Radiology. 2002;224(1):9-23. Reference #2: Jinbo Zhao, Nan Ma, Zhengwei Zhao, et al. Colobronchial fistula: the pathogenesis, clinical presentations, diagnosis and treatment. Journal of Thoracic Disease. 2017;9(1):187 DISCLOSURES: No relevant relationships by Brenda Affinati, source=Web Response No relevant relationships by Reid Stubbee, source=Web Response

Methods for Endoscopic Removal of Over-the-Scope Clip: A Systematic Review.

Aims The over-the-scope clip (OTSC) has recently emerged as a new endoscopic device for treating gastrointestinal bleeding, perforations, fistulas, and leaks. A modified OTSC device (full-thickness resection device, FTRD) has been widely used for endoscopic full-thickness resection. However, there is less experience regarding the indications and methods for OTSC removal. We aimed to summarize the existing methods and indications for OTSC removal. Methods We searched PubMed, Cochrane Library, and ClinicalTrials.gov to identify relevant publications on OTSC removal. The details of OTSC removal, including the methods, indications, success rates, adverse events, and failure causes, were extracted and summarized. A meta-analysis of pooled success rates was conducted using STATA 15.0. Results Eighteen articles were included. The reported methods for OTSC removal included (1) grasping forceps, (2) the Nd : YAG laser, (3) argon plasma coagulation, (4) the remOVE system, (5) endoscopic mucosal resection/endoscopic submucosal dissection, and (6) ice-cold saline solution. Indications for OTSC removal were (1) poor healing, (2) OTSC misplacement, (3) repeat biopsy/therapy or further treatment, (4) adverse events after OTSC implantation, (5) removal after recovery, and (6) patient wishes. The pooled success rate of OTSC removal was 89% in patients treated with the remOVE system. Minor bleeding, superficial thermal damage, and superficial mucosal tears were common adverse events. Mucosal overgrowth was the main cause of OTSC removal failure. Conclusions The remOVE system is the best investigated method, with sufficient efficacy and safety for OTSC removal. This is the first systematic review of OTSC removal and provides significant guidance for clinical practice.

Endoscopic management of gastrointestinal leaks and fistulae: What option do we have?

Gastrointestinal leaks and fistulae are serious, potentially life threatening conditions that may occur with a wide variety of clinical presentations. Leaks are mostly related to post-operative anastomotic defects and are responsible for an important share of surgical morbidity and mortality. Chronic leaks and long standing post-operative collections may evolve in a fistula between two epithelialized structures. Endoscopy has earned a pivotal role in the management of gastrointestinal defects both as first line and as rescue treatment. Endotherapy is a minimally invasive, effective approach with lower morbidity and mortality compared to revisional surgery. Clips and luminal stents are the pioneer of gastrointestinal (GI) defect endotherapy, whereas innovative endoscopic closure devices and techniques, such as endoscopic internal drainage, suturing system and vacuum therapy, has broadened the indications of endoscopy for the management of GI wall defect. Although several endoscopic options are currently used, a standardized evidence-based algorithm for management of GI defect is not available. Successful management of gastrointestinal leaks and fistulae requires a tailored and multidisciplinary approach based on clinical presentation, defect features (size, location and onset time), local expertise and the availability of devices. In this review, we analyze different endoscopic approaches, which we selected on the basis of the available literature and our own experience. Then, we evaluate the overall efficacy and procedural-specific strengths and weaknesses of each approach.

Fistulas Healing. Stable Gastric Pentadecapeptide BPC 157 Therapy.

This review is focused on the healing of fistulas and stable gastric pentadecapeptide BPC 157. Assuming that the healing of the various wounds is essential also for the gastrointestinal fistulas healing, the healing effect on fistulas in rats, consistently noted with the stable gastric pentadecapeptide BPC 157, may raise several interesting possibilities. BPC 157 is originally an anti-ulcer agent, native to and stable in human gastric juice (for more than 24 h). Likely, it is a novel mediator of Robert's cytoprotection maintaining gastrointestinal mucosal integrity. Namely, it is effective in the whole gastrointestinal tract, and heals various wounds (i.e., skin, muscle, tendon, ligament, bone; ulcers in the entire gastrointestinal tract; corneal ulcer); LD1 is not achieved. It is used in ulcerative colitis clinical trials, and now in multiple sclerosis, and addressed in several reviews. Therefore, it is not surprising that BPC 157 has documented consistent healing of the various gastrointestinal fistulas, external (esophagocutaneous, gastrocutaneous, duodenocutaneous, colocutaneous) and internal (colovesical, rectovaginal). Taking fistulas as a pathological connection, this rescue is verified with the beneficial effects in rats with the various gastrointestinal anastomoses, esophagogastric, jejunoileal, colo-colonic, ileoileal, esophagojejunal, esophagoduodenal, and gastrojejunal. This beneficial effect occurs equally when the gastrointestinal anastomoses are impaired with the application of NSAIDs, cysteamine, large bowel resection, as well as concomitant esophageal, gastric, and duodenal lesions and/or ulcerative colitis presentation, short bowel syndrome progression, liver and brain disturbances presentation. Particular aspects of the BPC 157 healing of the fistulas are especially emphasized.

Paclitaxel, Carboplatin, and Bevacizumab in Advanced Cervical Cancer: A Treatment Response and Safety Analysis.

Background:Trials reported there are beneficial effects of the addition of bevacizumab to chemotherapy in advanced cervical cancer but might have adverse effects. The purposes of the study were to evaluate the treatment response and safety of the addition of bevacizumab to paclitaxel plus carboplatin in advanced cervical cancer women.Methods:Data on treatment response, adverse effects, and overall survival of women who received paclitaxel plus carboplatin every 3 weeks (ACT cohort, n = 161) or paclitaxel, carboplatin, and bevacizumab every 3 weeks (PCB cohort, n = 127) until disease progression or severe adverse events were collected and analyzed.Results:The treatment response of paclitaxel plus carboplatin increased on addition of bevacizumab (P = .037). Neutropenia (grade ≥3, P = .001), leukopenia (grade 4, P = .041), anemia (grade ≥3, P = .031), hypertension (grade ≥2, P = .002), and gastrointestinal fistula (grade ≥2, P = 0.006) are reported in the PCB cohort. Women of ACT and PCB cohorts reported an overall survival of 20.11 ± 3.15 months and 24.52 ± 4.05 months, respectively.Conclusions:Addition of bevacizumab increases the treatment response of paclitaxel and carboplatin chemotherapy and overall survival of women with advanced cervical cancers, but it is not well tolerated.

Clinical efficacy of the over-the-scope clip device: A systematic review.

BACKGROUNDThe over-the-scope clip (OTSC) system has been increasingly utilized as a non-surgical option to endoscopically manage refractory gastrointestinal (GI) hemorrhage, perforations/luminal defects and fistulas. Limited data exist evaluating the efficacy and safety of OTSC.AIMTo determine the clinical success and adverse event (AE) rates of OTSC across all GI indications.METHODSA PubMed search was conducted for eligible articles describing the application of the OTSC system for any indication in the GI tract. Any article or case series reporting data for less than 5 total patients was excluded. The primary outcome was the rate of clinical success. Secondary outcomes included: Technical success rate, OTSC-related AE rate and requirement for surgical intervention despite-OTSC placement. Pooled rates (per-indication and overall) were calculated as the number of patients with the event of interest divided by the total number of patients.RESULTSA total of 85 articles met our inclusion criteria (n = 3025 patients). OTSC was successfully deployed in 94.4% of patients (n = 2856/3025). The overall rate of clinical success (all indications) was 78.4% (n = 2371/3025). Per-indication clinical success rates were as follows: (1) 86.0% (1120/1303) for GI hemorrhage; (2) 85.3% (399/468) for perforation; (3) 55.8% (347/622) for fistulae; (4) 72.6% (284/391) for anastomotic leaks; (5) 92.8% (205/221) for defect closure following endoscopic resection (e.g., following endoscopic mucosal resection or endoscopic submucosal dissection); and (6) 80.0% (16/20) for stent fixation. AE’s related to the deployment of OTSC were only reported in 64 of 85 studies (n = 1942 patients), with an overall AE rate of 2.1% (n = 40/1942). Salvage surgical intervention was required in 4.7% of patients (n = 143/3025).CONCLUSIONThis systematic review demonstrates that the OTSC system is a safe and effective endoscopic therapy to manage GI hemorrhage, perforations, anastomotic leaks, defects created by endoscopic resections and for stent fixation. Clinical success in fistula management appears limited. Further studies, including randomized controlled trials comparing OTSC with conventional and/or surgical therapies, are needed to determine which indication(s) are the most effective for its use.

Alternative uses of lumen apposing metal stents.

The advent of lumen apposing metal stents (LAMS) has revolutionized the management of many complex gastroenterological conditions that previously required surgical or radiological interventions. These procedures have garnered popularity due to their minimally invasive nature, higher technical and clinical success rate and lower rate of adverse events. By virtue of their unique design, LAMS provide more efficient drainage, serve as conduit for endoscopic access, are associated with lower rates of leakage and are easy to be removed. Initially used for drainage of pancreatic fluid collections, the use of LAMS has been extended to gallbladder and biliary drainage, treatment of luminal strictures, creation of gastrointestinal fistulae, pancreaticobiliary drainage, improved access for surgically altered anatomy, and drainage of intra-abdominal and pelvic abscesses as well as post-surgical fluid collections. As new indications of endosonographic techniques and LAMS continue to evolve, this review summarizes the current role of LAMS in the management of these various complex conditions and also highlights clinical pearls to guide successful placement of LAMS.

Enteral versus parenteral nutrition in the conservative treatment of upper gastrointestinal fistula after surgery: a multicenter, randomized, parallel-group, open-label, phase III study (NUTRILEAK study)

BackgroundPostoperative upper gastrointestinal fistula (PUGIF) is a devastating complication, leading to high mortality (reaching up to 80%), increased length of hospital stay, reduced health-related quality of life and increased health costs. Nutritional support is a key component of therapy in such cases, which is related to the high prevalence of malnutrition. In the prophylactic setting, enteral nutrition (EN) is associated with a shorter hospital stay, a lower incidence of severe infectious complications, lower severity of complications and decreased cost compared to total parenteral nutrition (TPN) following major upper gastrointestinal (GI) surgery. There is little evidence available for the curative setting after fistula occurrence. We hypothesize that EN increases the 30-day fistula closure rate in PUGIF, allowing better health-related quality of life without increasing the morbidity or mortality.Methods/designThe NUTRILEAK trial is a multicenter, randomized, parallel-group, open-label phase III trial to assess the efficacy of EN (the experimental group) compared with TPN (the control group) in patients with PUGIF. The primary objective of the study is to compare EN versus TPN in the treatment of PUGIF (after esophagogastric resection including bariatric surgery, duodenojejunal resection or pancreatic resection with digestive tract violation) in terms of the 30-day fistula closure rate. Secondary objectives are to evaluate the 6-month postrandomization fistula closure rate, time of first fistula closure (in days), the medical- and surgical treatment-related complication rate at 6 months after randomization, the fistula-related complication rate at 6 months after randomization, the type and severity of early (30 days after randomization) and late fistula-related complications (over 30 days after randomization), 30-day and 6-month postrandomization mortality rate, nutritional status at day 30, day 60, day 90 and day 180 postrandomization, the mean length of hospital stay, the patient’s health-related quality of life (by self-assessment questionnaire), oral feeding time and direct costs of treatment. A total of 321 patients will be enrolled.DiscussionThe two nutritional supports are already used in daily practice, but most surgeons are reluctant to use the enteral route in case of PUGIF. This study will be the first randomized trial testing the role of EN versus TPN in PUGIF.Trial registrationClinicalTrials.gov: NCT03742752. Registered on 14 November 2018.

Tu1028 POST-SURGICAL OR SPONTANEOUS RECALCITRANT LEAK MANAGEMANT USING NOVEL APPROACHES: ENDOSCOPIC DUPLICATION OF GUT VIA EXTRALUMINAL STENT (EDGES) & SUTURE OBTRUDED COVERED STENTS (SOCS)

Gastrointestinal fistulas, leaks, & perforations are associated with high morbidity and mortality as well as prolonged hospitalization. In 30-40% of patients the current management strategies such as wait & watch, transcutaneous drainage and endoscopic closure fail to resolve the symptoms adequately. We envisioned novel minimally invasive approaches to manage these defects. EDGES: used for recalcitrant fistulas with a para-luminal abscess cavity in the proximity of the GI tract. A pediatric upper endoscope was advanced through the fistula into the extra-luminal space. Under direct endoscopic view an intentional perforation was created to connect the distal most end of the abscess cavity to the gut lumen. A fully covered metal stent (Gore Viabil 10x100mm) was deployed from the gut lumen, through the fistula, across the abscess cavity, and back through the new perforation into the gut lumen. This approach prevented the entry of gut contents into the abscess to eventually allow the healing (Figure 1-4). SOCS: used in patients with recalcitrant fistulas with an abscess cavity that was not in the proximity of the GI tract to accomplish EDGES. A fully covered metal stent (Gore Viabil 10x100mm) was deployed ex-vivo. One of the ends of the stent was obtruded by proline suture & tested for complete sealing. Using a push or pull technique the obtruded end of the stent was passed from the lumen, through the fistula, into the abscess cavity & the open end remained in the gut lumen plugging the fistulous opening (Figure 5). We assessed the outcome of patients who underwent these techniques between April 2018 to Nov. 2019. The underlying cause of the defect and clinical follow-up as well as endoscopic & radiographic data was collected. We defined an endoscopic response as absence of a leak under endoscopic or fluoroscopic assessment of the GI defect. A total of 15 patients (5 female), mean age of 48 years were managed using EDGES in 6 patients & SOCS in 9 patients. Overall success of these novel approaches was 80%. Mean time to response was 89.5 days with an average follow-up of 166.3 days. EDGES was successful in 83% cases and SOCS was successful in 78% cases. 7(47%) patients had IBD, and one had malignancy; 5(33%) defects were gastric, 3(20%) were jejunal, 3(20%) were ileal, and 4(26.7%) were colonic. The average number of procedures prior to EDGES/SOCS was 5.4. Of the 3 patients who did not respond to endoscopic therapy, two patients failed therapy due to stent migration. Our novel, unconventional EDGES and SOCS approaches are promising to manage recalcitrant leaks. A consideration should be given to these approaches to avert high-risk surgery in a subset of patients.

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

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)

FAİLED ATTEMPT AT COLONİC PERFORATİON CLOSURE WİTH OVER THE SCOPE CLİP (OTSC): CASE REPORT

Giriş: Kolonoskopik perforasyon, alt gastrointestinal sistem görüntülemeleri sırasında görülebilecek en ciddi komplikasyonlardan bir tanesidir. Gastrointestinal sistem perforasyonu, hava kaçağına, gastrik veya intestinal sıvıların sızmasına, safra veya gaitanın batın içine sızması ile peritonit, pnömoperitonyum ve sepsis gibi ciddi durumlara neden olabilir. İatrojenik perforasyon yönetimi ve güvenli endoskopik kapatma teknikleri büyük ilgi görmektedir. Gastrointestinal perforasyonlarının kapatılması için over the scope clips (OTSC)'lerin through the scope clips(TTS)’e göre üstün olduğu bildirilmektedir. Biz bu yazıda sigmoid kolon perforasyonu nedeni ile OTSC uygulanan ancak başarısız olması nedeni ile TTS ile onarım sağlanan vakamızı sunmayı amaçladık.Olgu: 73 yaş kadın hastada kolonoskopi işlemi sırasında sigmoid kolon ortalarında kolonoskopi ilişkili perforasyon gelişmesi nedeni ile OTSC uygulandı ve defekt kapatıldı. Ancak birkaç dakika sonra yapılan kontrol kolonoskopide OTSC klipsin tuttuğu dokuyu bıraktığı görülmesi nedeni ile defekt 5 adet TTS klips ile kapatıldı. Tartışma: OTSC sistemi, gastrointestinal kanama, perforasyon, anastomoz kaçağı ve fistül tedavisinde başarıyla kullanılabilen yeni bir tekniktir. OTSC ile genel başarı oranının, iatrojenik gastrointestinal perforasyonların kapatılmasında % 75 ila % 100 arasında olduğu bildirilmekle beraber, başarılı OTSC uygulaması sonrası erken dönemde doku gerilimine bağlı olarak klipsin dokuyu bırakabileceği akılda tutulmalıdır.

Effect of addition of bevacizumab to chemoradiotherapy in newly diagnosed stage IVB cervical cancer: a single institution experience in Korea

ObjectiveThe aim of this study was to compare the clinical outcomes of chemoradiotherapy with or without bevacizumab in patients with newly diagnosed International Federation of Gynecology and Obstetrics (FIGO) stage...

Open abdomen treatment for complicated intra-abdominal infection patients with gastrointestinal fistula can reduce the mortality.

To evaluate the effect of the open abdomen (OA) and closed abdomen (CA) approaches for treating intestinal fistula with complicated intra-abdominal infection (IFWCIAI), and analyze the risk factors in OA treatment.IFWCIAI is associated with high mortality rates and healthcare costs, as well as longer postoperative hospital stay. However, OA treatment has also been linked with increased mortality and development of secondary intestinal fistula.A total of 195 IFWCIAI patients who were operated over a period of 7 years at our hospital were retrospectively analyzed. These patients were divided into the OA group (n = 112) and CA group (n = 83) accordingly, and the mortality rates, hospital costs, and hospital stay duration of both groups were compared. In addition, the risk factors in OA treatment were also analyzed.OA resulted in significantly lower mortality rates (9.8% vs 30.1%, P < .001) and hospital costs ($11721.40 ± $9368.86 vs $20365.36 ± $21789.06, P < .001) compared with the CA group. No incidences of secondary intestinal fistula was recorded and the duration of hospital stay was similar for both groups (P = .151). Delayed OA was an independent risk factor of death following OA treatment (hazard ratio [HR] = 1.316; 95% confidence interval [CI] = 1.068–1.623, P = .010), whereas early enteral nutrition (EN) exceeding 666.67 mL was a protective factor (HR = 0.996; 95% CI = 0.993–0.999, P = .018). In addition, Acinetobacter baumannii, Pseudomonas aeruginosa, and Candida albicans were the main pathogens responsible for the death of patients after OA treatment.OA decreased mortality rates and hospital costs of IFWCIAI patients, and did not lead to any secondary fistulas. Early OA and EN also reduced mortality rates.

Effects of a Perioperative Safety Checklist on Postoperative Complications Following Surgery for Gastric Cancer: A Single-Center Preliminary Study.

Objective. A Perioperative Safety Checklist (PSC) for gastric cancer (GC) was established to evaluate the effects of PSC on the clinical outcomes of GC. Methods. This single-center preliminary observational study conducted at a tertiary referral hospital included patients with GC who underwent surgery from January 1, 2016, to June 30, 2016, treated without PSC (allocated to the control group) and those who underwent surgery between January 1, 2017, and June 30, 2017, managed according to the PSC designated as the PSCGC (Perioperative Safety Checklist for Gastric Cancer) group. Results. Overall, 1072 cases were enrolled, 556 cases in PSCGC group and 526 cases in control group. After matching, there were 474 patients in each group. PSC intervention led to significant reductions of the incidence of postoperative intestinal fistula formation (P = .034), the incidence of unplanned secondary surgery (P = 0.039), and the total hospitalization expenses (P < .001). Total completion rate of all 14 checklists items was 79.1%. Intraoperative blood loss in the complete and partial implementation groups was significantly lower than the complete nonimplementation group (P = .002), whereas hospitalization cost showed an opposite trend, which was significantly higher in the incomplete nonimplementation group (P = .015). Conclusion. PSC implementation was associated with a decreased incidence of gastrointestinal fistula formation, unplanned secondary surgery, and hospitalization cost in patients with GC. However, it had no effect on the in-hospital mortality, the incidence of postoperative complications during hospitalization (ie, incision complications and lung infections), unplanned secondary admission, and the duration of postoperative hospital stay.

Filling of Polyglycolic Acid Sheets for Closure of Gastrointestinal Fistulas With an Easily Deliverable Technique Using a Guidewire.

BackgroundThis retrospective study aimed to investigate the suitable indications, methodology and long-term effect of the closure of gastrointestinal (GI) fistulas using polyglycolic acid (PGA) sheets and fibrin glue (FG) and to evaluate the usefulness of a delivery technique using a guidewire.MethodsIt involved 10 applications in six patients (median age 73 (range 53 - 78) years old, three men) with GI fistulas. A guidewire was introduced endoscopically or percutaneously into the fistula beyond the opposite orifice of the fistula with radiologic control. A tapered catheter was inserted over the guidewire, and the fistula was cleaned with an adequate quantity of saline. Subsequently, a small piece of PGA sheet was skewered onto the guidewire at the center and then pushed using the tapered catheter over the guidewire and delivered into the fistula. In cases of endoscopic procedure, the mucosa around the fistula was ablated, and the orifice of the fistula along with the surrounding mucosa was shielded with a piece of PGA sheet fixed with hemoclips and FG.ResultsTechnical success of fistula closure was achieved in all applications, and no complications were observed after the procedure. The long-term occlusion of the fistula was ultimately achieved in four of six patients at 202 - 654 days (median duration, 244 days) after the last procedure with one or two applications.ConclusionsThe closure of GI fistulas using PGA sheets and FG demonstrated long-term efficacy for upper GI fistula of a certain length, and the filling technique using a guidewire ensured a safe smooth procedure.

Gastrointestinal fistula endoscopic closure techniques.

With the improvement in flexible endoscopic technology and the availability of new endoscopic devices, current endoscopic therapies spare many patients who would otherwise undergo surgical repair of gastrointestinal fistulas. These endoscopic techniques include gastrointestinal stents, endoscopic suturing, cardiac septal occluders, endo-sponge, vacuum therapy and others. This review elaborates on the indications, evidence, procedural details, efficacy, and complications of various endoscopic techniques for the management of gastrointestinal fistulas.

Gastric Cancer Revealed by a Perforated Ulcer: A Case Report and Review

Introduction: Gastric cancer is not typically a surgical emergency. However, it can evolve into urgent complications such as a perforation. We report a case of a perforated gastric ulcer that turned out to be a cancer. Observation: A 52-year-old man was admitted to the emergency department of Hubert-Koutoukou-Maga National University Medical Center in Cotonou for generalized abdominal pain. He was diagnosed with acute generalized peritonitis with perforated gastric ulcer, establishing a surgical indication. An antral perforation was found and a simple closure was performed. Anatomopathological examination of the surgical piece revealed a gastric adenocarcinoma within the granulation tissue. Following the impact assessment, he underwent a second surgery where a distal gastrectomy was performed with D2 lymphadenectomy followed by gastrojejunostomy. He developed an anastomotic gastrointestinal fistula during the postoperative period but was successfully medically treated. The patient received adjuvant chemotherapy with Epirubicin, Cisplatin and 5-Fluorouracil. The patient is still alive, 3 years after the gastrectomy. Conclusion: When faced with a perforated gastric ulcer, one must also consider a neoplastic cause. The emergency surgical treatment depends on the general condition of the patient and the pre-existing co-morbidities, the choice being made between a one-stage versus two-stage gastrectomy.

Investigation of treatment and analysis of prognostic risk on enterocutaneous fistula in China: a multicenter prospective study

Objective: To investigate the diagnosis and treatment for enterocutaneous fistula (ECF) in China, and to explore the prognostic factors of ECF. Methods: A multi-center cross-sectional study was conducted based on the Registration System of Chinese Gastrointestinal Fistula and Intra-Abdominal Infections to collect the clinical data of ECF patients from 54 medical centers in 22 provinces/municipalities from January 1, 2018 to December 31, 2018. The clinical data included patient gender, age, length of hospital stay, intensive care unit (ICU) admission, underlying diseases, primary diseases, direct causes of ECF, location and type of ECF, complications, treatment and outcomes. All medical records were carefully filled in by the attending physicians, and then re-examined by more than two specialists. The diagnosis of ECF was based on the clinical manifestations, laboratory/imaging findings and intraoperative exploration. Results: A total of 1521 patients with ECF were enrolled, including 1099 males and 422 females, with a median age of 55 years. The top three primary diseases of ECF were malignant tumors in 626 cases (41.2%, including 540 gastrointestinal tumors, accounting for 86.3% of malignant tumors), gastrointestinal ulcers and perforations in 202 cases (13.3%), and trauma in 157 cases (10.3%). The direct causes of ECF were mainly surgical operation in 1194 cases (78.5%), followed by trauma in 156 (10.3%), spontaneous fistula due to Crohn's disease in 92 (6.0%), radiation intestinal injury in 41 (2.7%), severe pancreatitis in 20 (1.3%), endoscopic treatment in 13 (0.9%) and 5 cases (0.3%) of unknown reasons. All the patients were divided into three groups: 1350 cases (88.7%) with simple ECF, 150 (9.9%) with multiple ECF, and 21 (1.4%) with combined internal fistula. Among the patients with simple ECF, 438 cases (28.8%) were jejuno-ileal fistula, 313 (20.6%) colon fistula, 170 (11.2%) rectal fistula, 111 (7.3%) duodenal fistula, 76 (5.0%) ileocecal fistula, 65 (4.3%) ileocolic anastomotic fistula, 55 (3.6%) duodenal stump fistula, 36 (2.4%) gastrointestinal anastomotic fistula, 36 (2.4%) esophagogastric/esophagojejunal anastomotic fistula, 29 (1.9%) gastric fistula and 21 (1.4%) cholangiopancreatiointestinal. Among all the simple ECF patients, 991 were tubular fistula and 359 were labial fistula. A total of 1146 patients finished the treatment, of whom 1061 (92.6%) were healed (586 by surgery and 475 self-healing) and 85 (7.4%) died. A total of 1043 patients (91.0%) received nutritional support therapy, and 77 (6.7%) received fistuloclysis. Infectious source control procedures were applied to 1042 patients, including 711 (62.0%) with active lavage and drainage and 331 (28.9%) with passive drainage. Among them, 841 patients (73.4%) underwent minimally invasive procedures of infectious source control (replacement of drainage tube through sinus tract, puncture drainage, etc.), 201 (17.5%) underwent laparotomy drainage, while 104 (9.1%) did not undergo any drainage measures. A total of 610 patients (53.2%) received definitive operation, 24 patients died within postoperative 30-day with mortality of 3.9% (24/610), 69 (11.3%) developed surgical site infection (SSI), and 24 (3.9%) had a relapse of fistula. The highest cure rate was achieved in ileocecal fistula (100%), followed by rectal fistula (96.2%, 128/133) and duodenal stump fistula (95.7%,44/46). The highest mortality was found in combined internal fistula (3/12) and no death in ileocecal fistula. Univariate prognostic analysis showed that primary diseases as Crohn's disease (χ(2)=6.570, P=0.010) and appendicitis/appendiceal abscess (P=0.012), intestinal fistula combining with internal fistula (χ(2)=5.460, P=0.019), multiple ECF (χ(2)=7.135, P=0.008), esophagogastric / esophagojejunal anastomotic fistula (χ(2)=9.501, P=0.002), ECF at ileocecal junction (P=0.012), non-drainage/passive drainage before the diagnosis of intestinal fistula (χ(2)=9.688, P=0.008), non-drainage/passive drainage after the diagnosis of intestinal fistula (χ(2)=9.711, P=0.008), complicating with multiple organ dysfunction syndrome (MODS) (χ(2)=179.699, P<0.001), sepsis (χ(2)=211.851, P<0.001), hemorrhage (χ(2)=85.300, P<0.001), pulmonary infection (χ(2)=60.096, P<0.001), catheter-associated infection (χ(2)=10.617, P=0.001) and malnutrition (χ(2)=21.199, P<0.001) were associated with mortality. Multivariate prognostic analysis cofirmed that sepsis (OR=7.103, 95%CI:3.694-13.657, P<0.001), complicating with MODS (OR=5.018, 95%CI:2.170-11.604, P<0.001), and hemorrhage (OR=4.703, 95%CI: 2.300-9.618, P<0.001) were independent risk factors of the death for ECF patients. Meanwhile, active lavage and drainage after the definite ECF diagnosis was the protective factor (OR=0.223, 95%CI: 0.067-0.745, P=0.015). Conclusions: The overall mortality of ECF is still high. Surgical operation is the most common cause of ECF. Complications e.g. sepsis, MODS, hemorrhage, and catheter-associated infection, are the main causes of death. Active lavage and drainage is important to improve the prognosis of ECF.