Endoscopic Closure of Fistula

Introduction

A gastrointestinal fistula (fistula) refers to an anomalous connection that occurs between the gastrointestinal epithelium and another organ or external surface of the body. Surgical management of fistulas has been employed for several decades; nevertheless, these treatments have been linked to significant morbidity and mortality rates. The advancement of cutting devices and the innovation of self-expandable metal stents (SEMS) for removal have resulted in a notable enhancement of endoscopic procedures. The management of gastrointestinal fistulas underwent a significant transformation due to advancements in flexible endoscopic technology and the introduction of novel endoscopic equipment. Endoscopic therapies provide a viable alternative to surgical repair of fistulas, offering a means to spare a significant number of patients from undergoing invasive surgical procedures.

Why Are Fistula Closures Performed Endoscopically?

Endoscopic fistula closure treatment is a minimally invasive technique employed for the purpose of repairing a fistula, which refers to a hole or opening, utilizing an endoscope, a flexible imaging equipment. The utilization of an endoscope facilitates the medical practitioner in visually examining the internal structures of the body, enabling the identification and subsequent closure of the fistula. This procedure is conducted by a medical professional known as a gastroenterologist, who possesses specialized training in the diagnosis and treatment of gastrointestinal disorders.

• The utilization of an endoscopic method enables medical practitioners to perform the repair of a fistula as an outpatient operation.

• Patients undergoing this particular procedure may potentially have enhanced recovery rates, reduced susceptibility to infection, and diminished pain levels in comparison to individuals who choose laparoscopic or open-surgical interventions for rectifying the issue.

• If left untreated, the anomalous conduits (channels or pathways that deviate from the norm or exhibit unusual characteristics) have the potential to facilitate the escape of fluid from one organ to another or into neighboring bodily cavities and even outside the confines of the body.

• The occurrence of fluid leakage can lead to several adverse consequences, such as pain, infection, inflammation, organ damage, and mortality.

What Are the Potential Indications for Endoscopic Closure of a Gastrointestinal (GI) Fistula?

Endoscopy may not be the primary therapeutic intervention for gastrointestinal fistulas. The choice of treatment for a fistula may vary depending on its location, as determined by a gastroenterologist.

• In certain cases, the initial recommendation may involve prioritizing alternative treatments aimed at restoring the internal pH balance, thereby facilitating the healing process of the fistula.

• In the event that the fistula does not exhibit spontaneous closure after a few weeks, it may be advisable to consider endoscopic fistula closure as a potential course of action.

What Are the Various Methods Employed for Endoscopic Closure of Fistulas?

• Upper Gastrointestinal (GI) Endoscopic Fistula- Upper gastrointestinal (GI) endoscopic fistula closures are medical procedures utilized to address the repair of fistulas occurring in the esophagus, stomach, or small intestines. In the process of these particular procedures, the endoscope is introduced through the oral cavity.

• Lower Gastrointestinal Endoscopic Fistula- The procedure of lower gastrointestinal endoscopic fistula closures enables the medical intervention to access and effectively shut fistulas located inside the lower sections of the gastrointestinal tract, including the intestines, colon, or rectum as the endoscope is introduced into the rectum.

What Are the Potential Risks and Complications That May Arise From Endoscopic Fistula Repair?

Potential risks associated with the procedure encompass the possibility such as:

• Infection.

• Detachment of stents or clips from the site of surgery.

• The fistula might undergo reopening.

Typically, the incidence of problems associated with minimally invasive treatments is lower compared to operations utilizing a laparoscope or an open surgical technique.

What Are the Post-endoscopic Fistula Repair Recovery Procedures?

Upon completion of the designated protocol, the healthcare team will proceed to transfer the patient to a designated recovery area, where diligent monitoring will be conducted to ensure a safe transition as the sedative's effects gradually diminish. Patients will have the opportunity to engage in a discussion with their healthcare provider regarding their results prior to their departure.

During the process of recovery, it is possible that certain transient adverse effects may become apparent, including:

• The individual is experiencing discomfort and pain in their throat.

• The symptoms of nausea or vomiting.

• The occurrence of excessive gas, bloating, or cramping is attributed to the utilization of air for the purpose of expanding the surgical region during the process.

What Are the Steps Involved in Treatment?

Endoscopic methods are used to block the fistula location and restore luminal patency. Although there are several techniques, there are certain universal principles. To determine fistula anatomy and location, a radiographic contrast scan should be done before endoscopic stent implantation.

• Need for Endoscopic Units: The endoscopist needs fluoroscopy equipment. Complex therapeutic procedures like endoscopic retrograde cholangiopancreatography with metal stent implantation should be performed by skilled nursing assistants.

• Endoscopic Diagnosis: After informed consent, diagnostic endoscopy is performed.

After endoscopic identification of the fistulous aperture, water-soluble radiopaque contrast is injected to confirm the defect and measure the tract. This would also help the endoscopist find more leaks. Endoscopists should clean the spot under direct vision. This is crucial since the surrounding tissue may decide the closure method. If the luminal defect is wide enough, cautiously investigate the fistula tract with the endoscope under direct vision. Aspiration, saline irrigation, and baskets or snares should be used to debride the leak cavity under direct eyesight. Perianal fistulas can be cleaned and epithelium removed with a fistula brush. To avoid rupture, employ limited CO2 insufflation, especially in recently formed thin-walled cavities.

• Therapy Options and Post-op Care: In each case, the endoscopist should decide which next step will be most beneficial. The adequacy of the fistula site closure should be assessed during the surgery, shortly after closure, and during follow-up. This is done through water-soluble contrast radiography, computed tomography, or clinical fistula output measurement.

The choice of technique is contingent upon several factors, including the specific location of the defect, the size of the defect, the characteristics of the surrounding tissue, and the level of experience possessed by the endoscopist doing the treatment. Gastric fistulas may occasionally arise as a result of percutaneous gastrostomy tube removal or bariatric surgery. Insufficient long-term outcomes of endoscopic suturing are seen. The utilization of combination therapy has the potential to be beneficial in the treatment of esophageal fistulas. It is imperative to ensure the closure of the fistula throughout the surgical procedure, the subsequent recovery period, and the subsequent follow-up examinations.

Conclusion

The irritation from gastrointestinal secretions and gastrointestinal fistulas is difficult to control. Management is complicated by altered anatomy, cancer, or radiation harm. GIT fistulas are hard to treat despite improvements in endoscopic treatments during the past decade. Advanced endoscopy is less invasive and more physiological. Long-term success and efficacy are unknown. Technical and clinical results aside, endoscopic therapy may not work for all fistulas. A multidisciplinary approach is needed. Endoscopic gastrointestinal leak and fistula closures represent a big improvement in minimally invasive therapy.