92 patients with 117 non-acute full-thickness gastrointestinal defects (65 fistulas, 52 leaks) underwent OTSC therapy. With a median follow-up time of 5.5 months, overall defect closure success rate was 66.1 %. Only 14.9 % of patients underwent operative management. No complications related to endoscopic intervention occurred and no patients required urgent surgical intervention.
D.J Morrell et al., Department of Surgery, Division of Minimally Invasive and Bariatric Surgery, Penn State Health Milton S. Hershey Medical Center, Hershey, PA, USA, conducted a study evaluating endoscopic management of non-acute full-thickness gastrointestinal defects (FTGID) using the OTSC (Ovesco Endoscopy AG, Tuebingen, Germany).
Non-acute FTGID, when compared to acute perforations, are typically more difficult to manage due to a delayed diagnosis and/or chronicity. The open surgical management of these defects is often challenging and related to substantial morbidity, requiring washout and drainage of infection, takedown or recreation of surgical anastomoses, deviation stoma formation and/or parenteral nutrition.
For the study, all patients undergoing OTSC management of FTGID between 2013 and 2019 were identified. Acute perforations and defects requiring endoscopic suturing were excluded. The endoscopic methodology to approach FTGID included treating underlying infection, optimizing nutrition, removing foreign bodies, de-epithelizing/ablating mucosa, relieving downstream obstructions and collecting GI effluent. Success was strictly defined as complete FTGID closure, patients with multiple FTGID were only counted as successfully managed if all FTGID were closed at the end of follow-up.
Overall, 92 patients (mean age 54.6 ± 15.4 years, 64.1 % female) with 117 FTGID (65 fistulas, 52 leaks) met the inclusion criteria. The majority of defects was located in the upper GI tract (64.1 %). The estimated defect diameter was 4.6 mm for leaks and 6.8 mm for fistulas. Overall prior intervention rate was 40.2 % with a mean of 0.56 prior interventions. The OTSC was used for treatment in all cases. Median follow-up time was 5.5 months (interquartile range 2.2 – 14.8). Long-term complete FTGID closure was achieved in 66.1 % (55.0 % fistulas vs 79.6 % leaks, p = 0.007). Additional closure attempts were required in 22.2 % of FTGID. Patients with failed FTGID closure in comparison to patients with successful closure were more likely to have had a history of radiation treatment at the defect site (12.9 % vs 1.8 %, p = 0.0329). Besides, a history of previous smoking was also more common in patients with unsuccessful closure (67.7 % vs 32.1 %, p = 0.0014).
No complications related to endoscopic intervention occurred. There were 4 mortalities from causes unrelated to the FTGID. Only a small subset of patients (14.9 %) ultimately underwent surgical management, no patients required urgent operative intervention.
The authors concluded that OTSC management of delayed or chronic full-thickness gastrointestinal defects is safe and effective and constitutes an attractive alternative to potentially morbid surgical management.
Over-the-scope clip management of non-acute, full-thickness gastrointestinal defects
Morrell DJ, Winder JS, Johri A, Docimo S, Juza RM, Witte SR, Alli VV, Pauli EM.
Surg Endosc (2019). https://doi.org/10.1007/s00464-019-07030-3