Successful Endoscopic Closure Research Articles

CYANOACRYLIC GLUE: A MINIMALLY INVASIVE NONSURGICAL FIRST LINE APPROACH FOR THE TREATMENT OF SOME URINARY FISTULAS

We evaluated the adaptability and the efficacy of a cyanoacrylic glue for the conservative treatment of urinary fistulas of different etiologies using an endoscopic, percutaneous or endovaginal approach. From May 1998 to July 2004, 13 patients with long lasting iatrogenic and/or inflammatory urinary fistulas were treated conservatively with endoscopic, percutaneous or endovaginal application of 1 to 3 cc of cyanoacrylic glue. The complication rate in this cohort of 13 patients was low. Occlusion therapy failed in 2 genitourinary fistulas which were wider (diameter greater than 1 cm) and short. In the remaining 11 cases urinary fistulas were successfully sealed and at a median followup of 35 months no relapses were observed. Cyanoacrylic glue is suitable for endoscopic, percutaneous and endovaginal use. This occlusion therapy represents a safe and minimally invasive approach that might be offered as a first line option for the treatment of urinary fistulas, especially narrow and long tract fistulas.

CLOSURE OF GASTROINTESTINAL FISTULAS WITH ENDOCLIPS-EVIDENCE BASED MEDICINE REVIEW OF LITERATURE

Purpose: Although a number of randomized controlled trials are available demonstrating the efficacy of endoclip application in the management of gastrointestinal bleeding, information on the role of endoclips in treating gastrointestinal perforations is limited. The aim of this study is to present an evidence based medicine (EBM) review of literature on the role of endoclips in the management of gastrointestinal perforations, fistulas, and leaks. Methods: A MEDLINE search of English language publications was performed from 1966 to June of 2003 related to endoclipping by using the keywords “endoclip” or “hemoclip.” An overall quality assessment of the available publications was done according to EBM. Results: First Report: Binmoeller et al reported successful endoscopic closure of a gastric perforation using metallic clips after snare excision of a gastric leiomyoma in 1993. Case Reports: 38 cases of gastrointestinal perforations, fistulas, and anastamotic leaks treated by the endoscopists with endoclips without a need for laparotomy have been published in peer-reviewed journals. Randomized Controlled Trials: None. Closure of Perforations, Fistulas, and Leaks: The endoclips were successful in the closure of perforations, fistulas, and leaks of the esophagus, stomach, duodenum, and colon. a. Esophageal Perforations: Endoclipping was successful in the closure of esophageal perforations resulting from endoscopy, bougeinage of esophageal stricture, balloon dilation of anastomotic strictures, pneumatic balloon dilation of achalasia, fish bone ingestion, metal hook ingestion, Mallory-Weiss tear, Boerhaave's syndrome, and empyema. b. Gastroduodenal perforations resulting from endoscopic ultrasound examination, snare polypectomy of gastric tumors, endoscopic mucosal resection of early gastric cancer, biliary sphincterotomy, ampullectomy, and biliary stent migration have been successfully closed by endoclipping. c. Colonic perforations from colonoscopy and endoscopic mucosal resection of colonic neoplasia, colo-cutaneous fistulas following a PEG placement and rupture of periappendicial abscess, and colo-vesical fistula from diver-ticulitis have been successfully closed with endoclips. Nature of Defect Closed: Fresh perforation to a chronic fistula of 2 to 3 months and defect of 0.5 cm to 2.5 cm. Details of each case report will be presented in a tabular form for the poster. Evidence for endoclip closure of gastrointestinal fistulas: Grade B. Conclusions: Endoclips are useful in the closure of perforations, fistulas, and anastomotic leaks.

Hello, Mr. Clips—could you chip in please?

Hello, Mr. Clips—could you chip in please?

Postoperative bronchopleural fistula: endoscopic closure in 12 patients

Twelve consecutive patients with postresectional bronchopleural fistula were treated with endoscopic application of tissue glue adhesive (methyl-2-cyanoacrylate). Eight patients had associated empyema. Endoscopic gluing was successfully accomplished in 10 cases (success rate of 83%). The two failures both had fistulas of 0.5 cm or larger. Bronchopleural fistulas developed in 8 patients early after the intervention (< 15 days): of the 4 patients without associated empyema, 3 had their fistula definitely closed after endoscopic treatment. Similarly, 3 of the 4 patients with early bronchopleural fistulas and empyema were cured after endoscopic closure of the fistula and appropriate management of the empyema. Four bronchopleural fistulas occurred later after the operation (> 15 days) and all had associate empyema. Successful endoscopic closure of the fistula was accomplished in all. Resolution of the empyema occurred in 1. We conclude that endoscopic application of tissue adhesive may be a valid therapeutic measure in selected patients with postresectional bronchopleural fistula. In late bronchopleural fistula with empyema, the closure of the fistula can be achieved, but empyema may persist and require additional surgical procedures.

Successful long-term endoscopic closure of a recurrent tracheoesophageal fistula with fibrin glue in a child

We present an unusual case of recurrent tracheoesophageal fistula after primary surgical repair of congenital esophageal atresia. Traditionally, this disorder has required open-surgical correction, but successful endoscopic closure of these fistulas has been reported. This case report describes our experience using fibrin glue, applied endoscopically in a 6-year-old child, with encouraging long-term results 4 years after treatment.

Use of Electrocoagulation in the Treatment of Vesicovaginal Fistulas

The role of electrocoagulation for the treatment of vesicovaginal fistulas has not been clearly defined. To determine the use of this therapeutic modality, 15 cases of fistulas treated with electrocoagulation were retrospectively reviewed. Fulguration represented the primary treatment in 12 patients and the secondary treatment in 3 after an initial attempt at open surgical closure failed. In all instances fistula size was estimated to be 3.5 mm. or less. A Bugbee electrode, which was inserted into the fistula either cystoscopically or vaginally, was used to destroy the epithelial lining of the fistula tract. Following the procedure the bladder was decompressed with a large indwelling Foley catheter for at least 2 weeks. Fulguration was successful as the sole treatment modality in 9 of 12 patients (75%) and as an alternative intervention after failure of an open surgical repair in 2 of 3 (66%). Therefore, 11 of the 15 women (73%) had complete resolution of the fistulas with this technique. We conclude that fulguration is usually effective in managing patients with vesicovaginal fistulas a few millimeters in size or less. This technique should be used as an initial treatment for appropriately selected patients and in women with small residual fistulas after open surgical failure.

Postoperative bronchoplenral fistula: Endoscopic closure in 12 patients

Twelve consecutive patients with postresectional bronchopleural fistula were treated with endoscopic application of tissue glue adhesive (mefhyl-2-cyanoacrylate). Eight patients had associated empyema. Endoscopie gluing was successfully accomplished in 10 cases (success rate of 83%). The two failures both had fistulas of 0.5 cm or larger. Bronchopleural fistulas developed in 8 patients early after the intervention (<15 days): of the 4 patients without associated empyema, 3 had their fistula definitely closed after endoscopie treatment. Similarly, 3 of the 4 patients with early bronchopleural fistulas and empyema were cured after endoscopic closure of the fistula and appropriate management of the empyema. Four bronchopleural fistuias occurred late after the operation (>15 days) and all had associated empycma. Successful endoscopic closure of the fistula was accomplished in all. Resolution of the empyema occurred in 1. We conclude that endoscopic application of tissue adhesive may be a valid therapeutic measure in selected patients with postresectional bronchopleural fistula. In late bronchopleural fistula with empyema, the closure of the fistula can be achieved, but empyema may persist and require additional surgical procedures.