Endoscopic Repair of Postoperative

Gastrointestinal Fistulae Using a Novel

Endoscopic Suturing Device:

Technical Feasibility and Safety

Rabindra R Watson, Pichamol Jirapinyo, Christopher C. Thompson

BRIGHAM AND WOMEN’S HOSPITAL

HARVARD MEDICAL SCHOOL

No Disclosures

Rabindra R Watson, M.D.

Division of Gastroenterology

Brigham & Women’s Hospital

Harvard Medical School

Boston, MA, USA

Introduction: Background

• Gastrointestinal fistulae (GF) complicate

a variety of operations• Cancer operations

• 0-46% of open gastric bypass

• 1-6% of laparoscopic divided gastric bypass

• Associated with morbidity, increased

healthcare costs, prolonged hospitalization

Introduction: Background

• Surgical repair of GF can be technically

challenging due to adhesions and

fibrosis

• Morbidity up to 50%

• Mortality 2%

• Endoscopic therapy presents a less

invasive alternative

Introduction: Endotherapy

• Clips:

• Endoclips – esophageal leaks, perforations

• Over the scope clips

• Limited by fibrosis, fistula size, durability

Introduction: Endotherapy

• Injectable Agents

• Fibrin Glue:

• Thrombin + calcium + aponectin + fibrin = acellular clot

• Cyanoacrylates

Introduction: Endotherapy

• Stents:

• Covered metal stents

• Migration, tissue overgrowth

• Anatomy

Introduction: Endotherapy

• Endoscopic Suturing:

Introduction: Setting

• Our institution is a large tertiary referral

center for bariatric surgery and complications

• Experience with endoscopic treatment of GF

using a variety of techniques

Aim:

To evaluate a novel endoscopic

suturing device in the treatment of

gastrointestinal fistulae with respect to

technical feasibility and safety

Introduction: Suturing Device

Reproduced with permission by manufacturer

Methods: Argon Plasma Coagulation

Methods: Suturing

Methods: Fibrin Glue

Methods: Post-Procedure Care

• All patients discharged on PPI

• NPO day of procedure

• Clear liquids full liquids x 2 weeks

• Liquid Tylenol for pain

Methods:

• Technical Success: Intact deployment

of suture across fistula os

• Early complications (<48 hours)

• Follow-up: radiography, endoscopy

clinical

Patients:

Age Sex Operation

Time Interval

(mo)

Diameter (mm)

Symptoms

Patient 1 48 F LAR 5 8 Rectovaginal Fistula

Patient 2 40 M RYGB 144 6 Weight regain

Patient 3 70 M Esophagectomy 5 8 Mediastinitis

Patient 4 58 F RYGB 6 20 Weight regain

Patient 5 59 M RYGB 10 7 Weight regain

Patient 6 55 F RYGB 34 5 Weight regain

Patient 7 61 F RYGB 96 10 Weight regain

51.9 8.7±5.2

Results:

# of Sutures

Procedure Length (min)

Technical Success

Patient 1 1 25 Yes

Patient 2 1 12 Yes

Patient 3 1 30 Yes

Patient 4 3 30 Yes

Patient 5 1 60 Yes

Patient 6 1 60 Yes

Patient 7 1 9 Yes

1.3 36.1±19.6 100%

Results: Complications

• No early complications

• Post-procedure abdominal pain commonly

reported, managed conservatively

Results: Follow-up

Follow-up Interval (mo)

Operation Confirmation Outcome

Patient 1 6 LAR Barium Enema Failure

Patient 2 6 RYGB Endoscopy No Sx, Weight Loss

Patient 3 5 Esophagectomy Endoscopy Resolution

Patient 4 5 RYGB Clinical No Sx, Weight Loss

Patient 5 6 RYGB Clinical No Sx, Weight Loss

Patient 6 5 RYGB Clinical No Sx, Weight Loss

Patient 7 3 RYGB Clinical No Sx, Weight Loss

5.1

Results: Follow-up

Follow-up Interval (mo)

OperationWeight loss (pounds)

Patient 2 6 RYGB 24

Patient 4 5 RYGB 22

Patient 5 6 RYGB 20

Patient 6 5 RYGB 27

Patient 7 3 RYGB 23

22.8±2.4

Pouch reduction?

Limitations

• Single expert center experience

• Small number of patients

• Follow-up Interval

Conclusions

• Endoscopic repair of various GF is technically feasible using this novel suturing device

• Fistula repair can be achieved safelywithin a short procedure time

• Further study is underway regarding durability and long-term success rates

Endoscopic Repair of Postoperative

Gastrointestinal Fistulae Using a Novel

Endoscopic Suturing Device:

Technical Feasibility and Safety

Rabindra R. Watson, Pichamol Jirapinyo, Christopher C. Thompson

BRIGHAM AND WOMEN’S HOSPITAL

HARVARD MEDICAL SCHOOL

Introduction: Suturing Device