fistula repair with apollo overstitch - presentation ddw 2011
DESCRIPTION
Chris Thompson's early data on gastrogastric fistula repair presented @ DDW (Chicago, 2011)TRANSCRIPT
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