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

Abstract

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.

Keywords: Leak; Fistula; Endotherapy; Over-the-scope clip; Suturing system; Endo-vacuum therapy; Endoscopic internal drainage; Self-expandable metal stent

Core tip: Early diagnosis of gastrointestinal leaks and fistulae is associated with better outcomes. Endoscopic minimally invasive management is becoming the treatment of choice for gastrointestinal wall defects. It is more effective and safer than surgery. Several endoscopic devices and techniques are available, and they include endoclip, metal or plastic stent, tissue sealants, suturing systems and vacuum therapy. The choice of one procedure over another should depend on clinical presentation, defect features and local expertise. Early leaks have a higher rate of longstanding healing compared to late leaks and fistulae. A close collaboration between surgeons, interventional radiologists and therapeutic endoscopists is recommended to assure a favorable outcome.