Endoscopic Treatment of Enterocutaneous Fistulas in Crohn's Disease.

BACKGROUND: Management of enterocutaneous fistulas in Crohn's disease is challenging. Most patients still need intestinal resection in the biologic era. OBJECTIVE: The aim of this study was to evaluate the efficacy of endoscopic treatment for enterocutaneous fistulas. DESIGN: This is a retrospective study of medical records. SETTINGS: This study was conducted in a single institution. PATIENTS: All consecutive patients with Crohn's disease with an enterocutaneous fistula who underwent endoscopic fistula closure with the use of an over-the-scope clip or a hemostatic clip were included. MAIN OUTCOME MEASURES: The main outcome measured was the clinical success 3 months after the procedure, which was defined as the complete closure of all fistulas at physical examination and complete cessation of the drainage from the external opening, without surgery. RESULTS: Eight patients (men, 25%; median age 45 years [interquartile range, 33-51]) were followed. Fistulas were localized at the ileocolonic or colocolonic anastomosis in 7 patients and at the stomach in 1 patient. Seven patients were treated with an over-the-scope clip, and one was treated with a hemostatic clip. Technical success was achieved in all cases. Clinical success at 3 months was achieved in 75% of cases (6/8 patients). After a median 16-month (interquartile range, 13-23) follow-up, 3 of 8 (37.5%) patients had enterocutaneous fistula closure and 2 of 8 (25%) needed intestinal resection. No complications were observed. LIMITATIONS: The retrospective nature, the small sample size of the study, and the heterogeneity of the population limit the interpretation of the results. CONCLUSIONS: Endoscopic treatment of enterocutaneous fistulas is feasible with a short-term effectiveness. Additional studies are needed to confirm these results. See Video Abstract at http://links.lww.com/DCR/B614. TRATAMIENTO ENDOSCPICO DE FSTULAS ENTEROCUTNEAS EN ENFERMEDAD DE CROHN: ANTECEDENTES:Es desafiante el manejo de las fístulas enterocutáneas en enfermedad de Crohn. En la era biológica, la mayoría de los pacientes todavía requieren de resección intestinal.OBJETIVO:Evaluar la eficacia por tratamiento endoscópico de fístulas enterocutáneas.ENTORNO CLINICO:Estudio retrospectivo de registros médicos.AJUSTE:Realizado en una sola institución.PACIENTES:Se incluyeron todos los pacientes consecutivos con fístula enterocutánea en enfermedad de Crohn, sometidos a cierre endoscópico de la fístula con clip sobre el endoscopio o clip hemostático.PRINCIPALES MEDIDAS DE VALORACION:El éxito clínico a los 3 meses después del procedimiento. Definido al examen físico, como el cierre completo de todas las fístulas y cese completo del drenaje por la abertura externa, sin cirugía.RESULTADOS:Se estudiaron a ocho pacientes (hombres, 25%, mediana de edad de 45 años (rango intercuartílico, 33-51)). En 7 pacientes, las fístulas se localizaron en la anastomosis ileocolónica o colocolónica y un paciente, en el estómago. Siete pacientes fueron tratados con clip sobre el endoscopio y uno con clip hemostático. Se logró éxito técnico en todos los casos. Se logró éxito clínico a los 3 meses en 75% de los casos (6/8 pacientes). Después de una mediana de 16 meses (rango intercuartílico, 13-23), de seguimiento 3/8 (37,5%) pacientes presentaron cierre de fístulas enterocutáneas y 2/8 (25%) requirieron resección intestinal. No se observaron complicaciones.LIMITACIONES:Estudio retrospectivo, pequeño tamaño de la muestra y heterogeneidad de la población, limitaron la interpretación de los resultados.CONCLUSIONES:Es posible el tratamiento endoscópico de fístulas enterocutáneas con efectividad a corto plazo. Se requieren nuevos estudios para confirmar estos resultados. Consulte Video Resumen en http://links.lww.com/DCR/B614. (Traducción-Dr. Fidel Ruiz Healy).

Endoscopic treatment of large gastric leaks after gastrectomy using the combination of double pigtail drains crossing a covered stent.

BACKGROUND: Endoscopy is the gold standard for the treatment of postoperative gastric leaks (GL). Large fistulas are associated with high rate of treatment failure. The objective of this study was to assess the clinical efficacy of a combining technique using a covered stent (CS) crossing through pigtails (PDs) for large postsurgical GL leaks. METHODS: All consecutive patients with large (> 10 mm) postsurgical GL treated endoscopically with a combination of a CS and PDs were included in a single-center retrospective study. The primary endpoint was the rate of GL closure. RESULTS: A total of 29 patients were included. Twenty-five patients underwent sleeve gastrectomy. The fistula (median diameter 15 mm) was diagnosed 6 days (IQR 4-9) after surgery. Technical success was observed in all procedures. After a median follow-up of 10.7 months (IQR 3.8-20.7), GL closure was observed in 82.7% with a median time of 63 days (IQR 40-90). Surgical management was finally necessary in four patients after a median of 186 days (IQR 122-250). No complications related to combined endoscopic treatment were observed especially stent migration during the follow-up. CONCLUSION: An endoscopic strategy combining CS crossing through PDs appears to be effective, safe and well tolerated for the treatment of large GL.

Safety and efficacy of percutaneous transhepatic-endoscopic rendezvous procedure in a single session.

PURPOSE: To demonstrate the feasibility and safety of PTE-RV performed in a single session. MATERIALS AND METHODS: This is a retrospective review of a prospective database on ERCP between January 2014 and December 2018. PTE-RV was performed in case of second ERCP failure. Technical success was defined as the establishment of an intestinal access to the biliary tract using a PTE-RV procedure allowing an immediate internal biliary drainage. Safety endpoints included intra-operative complications, morbidity and mortality occurring within 30 days after the procedure. RESULTS: Eighty-four patients (44 M/40F) with a median age of 69 years (range 40-91 years) underwent combined PTE-RV. The PTE-RVs were successfully performed in the same session in 80 subjects, resulting in an overall technical success rate of 95.2%. Adverse events were observed in 19% (16/84) of cases. The mortality rate within 30 days after the procedure was 9.5%. CONCLUSION: Percutaneous transhepatic-endoscopic rendezvous technique is feasible in a single session with acceptable level of risk. A randomized trial is required to compare EUBD and PTE-RV.

Laparoscopy-assisted open cystogastrostomy and pancreatic debridement for necrotizing pancreatitis (with video).

INTRODUCTION: Pancreatic pseudocysts and walled-off necrosis are well-known complications, described in 10% of cases of acute pancreatitis. Open cystogastrostomy is usually proposed after failure of minimally invasive drainage or in the presence of septic shock. The objective of this study was to evaluate the feasibility and efficacy of laparoscopy-assisted open cystogastrostomy for treatment of symptomatic pancreatic pseudocyst with pancreatic necrosis. MATERIALS AND METHODS: Between January 2011 and October 2014, all patients with pseudocyst and pancreatic necrosis undergoing open cystogastrostomy were included. Surgical procedure was standardized. The primary efficacy endpoint was the feasibility and efficacy of laparoscopy-assisted open cystogastrostomy as treatment of symptomatic pancreatic pseudocyst. Secondary endpoints included demographic data, preoperative management, operative data, postoperative data and follow-up. RESULTS: Laparoscopy-assisted open cystogastrostomy was performed in 11 patients [six men (54%)], with a median age of 61 years (45-84). Nine patients received preoperative radiological or endoscopic management. First-line open cystogastrostomy was performed in two cases. Median operating time was 190 min (110-240). There was one intraoperative complication related to injury of a branch of the superior mesenteric vein. There were no postoperative deaths and two postoperative complications (18%) including one major complication (postoperative bleeding). The median length of hospital stay after surgery was 16 days (7-35). The median follow-up was 10 months (2-45). One patient experienced recurrence during follow-up. CONCLUSION: Open cystogastrostomy for necrotizing pancreatitis promotes adequate internal drainage with few postoperative complications and a short length of hospital stay. However, this technique must be performed very cautiously due to the risk of vascular injury which can be difficult to repair in the context of severe local inflammation related to pancreatic necrosis.

Adjunctive proximal aortic and aortodistal prosthetic wrapping of vascular anastomoses for Adamantiadis-Behçet's aortic/aortoiliac aneurysms: A revisit.

BACKGROUND: We described our local experiences with a single-layer wrapping technique for the vascular anastomoses in patients with Adamantiadis-Behçet's aortic/aortoiliac aneurysms using InterGard Silver-impregnated Dacron® patch prosthesis. METHODS: Between January 2013 to December 2019, we retrospectively reviewed 20 patients presented with Adamantiadis-Behçet's aortic/aortoiliac aneurysms. All patients presented with Adamantiadis-Behçet's aortic/aortoiliac aneurysms. Two groups were analyzed, Group I, considered as a control group (n = 20). While group II (n = 20), of which prosthetic wrapping was performed. Follow up took place for a maximum of 24 months. RESULTS: during a six-year retrospective study period, 20 patients were recruited. They included 15 males and five females (ratio 3:1). The median age was 30.5 ± 4.2 years. Anastomotic pseudoaneurysms were reported in group I (control, [non-wrapping group]). While group II doesn't (wrapping group). Paired samples t test revealed a significant difference between those underwent wrapping and those with non-wrapping (p = .019 and .038). False aneurysms were reported in 80% of the non-wrapping group as estimated by the Kaplan-Meier curves. While Log-rank test results revealed a significant difference between both the studied groups (p < .008). Primary graft patency was 90% at 24 months as reported by the Kaplan-Meier survival method. CONCLUSIONS: adjunctive wrapping for vascular anastomoses using Intergard Silver-impregnated Dacron® patch in patients with Adamantiadis-Behçet's aortic/aortoiliac aneurysms is an applicable, simple, and reliable technique. It was associated with low morbidity and mortality rates. Moreover, we discussed a relatively old technique aiming to explore its success and safety in treating arterial aneurysms in Adamantiadis-Behçet's disease patients.

How can recovery be enhanced after single-stage laparoscopic management of CBD stones? Endoscopic treatment versus laparoscopic surgery.

BACKGROUND: Single-stage management of CBD stones comprises simultaneous common bile duct (CBD) clearance and cholecystectomy. The CBD can be cleared by using endoscopic treatment (ET) or laparoscopic surgery (LS) alone. AIMS: To determine the most rapid recovery after the single-stage laparoscopic management of CBD stones. METHODS: Patients with CBD stones treated at either of two centers (one performing ET only and one performing LS only for single-stage treatment) were included. The primary endpoint was "the textbook outcome". RESULTS: The feasibility rate was 74% for ET and 100% for LS (p≤0.001). The proportion of cases with the textbook outcome was higher in the ET group than in the LS-only group (73% vs. 10%; p<0.001). The CBD clearance rate was similar in the ET and LS-only groups (100% vs. 96.6%, respectively; p=0.17). The overall morbidity rate was lower in the ET group than in the LS-only group (23% vs. 29%, p=0.05). CONCLUSION AND RELEVANCE: Both ET and LS are feasible, safe and effective for clearance of the CBD. ET was better than LS in terms of a less frequent requirement for drainage and a shorter length of hospital stay. LS was associated with a shorter operating time.

New endoscopic technique for the treatment of large gastric fistula or gastric stenosis associated with gastric leaks after sleeve gastrectomy.

BACKGROUND: Covered stent (CS) is required when gastric leak (GL) after sleeve gastrectomy is combined with gastric stenosis (GS) or when a large (>2 cm in diameter) gastric fistula is present (increasing the likelihood of double pigtail stent [DPS] migration). OBJECTIVE: To compare the results of our previous endoscopic management of large GL or GS associated with GL (using CS only) with those of our new endoscopic treatment (using combined CS and DPS). SETTING: University hospital, France, public practice. MATERIAL AND METHODS: Between January 2009 and June 2015, all patients treated for large GL or GS associated with GL after sleeve gastrectomy (n = 20 patients) were included. Our previous endoscopic management required CS placement (CS group), whereas our new endoscopic treatment required combined CS and DPS placement (CS+DPS group). The primary efficacy endpoint was the treatment duration after CS placement until closure of the GL. The secondary efficacy endpoints were the number of endoscopic procedures, the stent migration rate, and the failure rate. RESULTS: Nine patients were treated by CS only (CS group), whereas 11 patients were treated by both CS and DPS (CS+DPS group). The median time to GL closure after CS placement was 84 days (33-130) in the CS group and 32 days (26-89) in the CS+DPS group (P≤.05). The median number of endoscopic procedures at the time of CS placement was 2 (1-3) in the CS group and 1 (1-2) in the CS+DPS group (P≤.05). The stent migration rate after CS placement was 33.3% in the CS group and 0% in the CS+DPS group (P = .21), and the failure rate was 11% and 0% (P = .36). CONCLUSION: The combination of CS and DPS constitutes an effective treatment for large GL or GS associated with GL, allowing significantly fewer endoscopic procedures and a shorter treatment duration.

Gastric Stenosis After Laparoscopic Sleeve Gastrectomy: Diagnosis and Management.

PURPOSE: The use of laparoscopic sleeve gastrectomy (LSG) is increasing worldwide. Although post-LSG gastric stenosis (GS) is less frequent, it has not been well defined and lacks standardized management procedures. The objective of the present study was to describe a series of patients with GS symptoms after LSG and to develop a standardized management procedure for this complication. METHODS: We performed a retrospective analysis of a prospective database of patients presenting with GS after LSG procedures performed between January 2008 and March 2014. The primary efficacy criterion was the frequency of post-LSG GS. GS was classified as functional (i.e. a gastric twist) or organic. The secondary efficacy criteria included the time interval between LSG and diagnosis of GS, the type of stenosis, the type of management, and the follow-up data. RESULTS: During the study period, 1210 patients underwent primary or secondary LSG. Seventeen patients had post-operative symptoms of GS (1.4%); one patient had achalasia that had not been diagnosed preoperatively and thus was excluded from our analysis. The median time interval between LSG and diagnosis of GS was 47.2 days (1-114). Eleven patients had organic GS and six had functional GS. Seven patients required nutritional support. Endoscopic treatment was successful in 15 patients (88.2%) after balloon dilatation (n = 13) or insertion of a covered stent (n = 2). Two of the 15 patients required conversion to Roux-en-Y gastric bypass (11.8%). CONCLUSION: GS after LSG is a rare complication but requires standardized management. Most cases can be treated successfully with endoscopic balloon dilatation.

Persistent gastric fistula after sleeve gastrectomy: an analysis of the time between discovery and reoperation.

BACKGROUND: Gastric leak (GL) represents one of the main early-onset postoperative complication of sleeve gastrectomy (SG). Most studies of GL featured short series and no data on the time to reoperation for persistent GL. OBJECTIVES: Characterize the time between discovery of persistent post-SG GL and the implementation of reoperation. SETTING: University hospital, France, public practice. METHODS: All patients treated for post-SG GL between November 2004 and December 2013 were included. The primary efficacy criterion was the time interval between discovery of a persistent GL and reoperation. The secondary efficacy criteria were demographic, surgical, and endoscopic data; mortality rate; time to GL healing; treatment success rate; and risk factors for failure treatment. RESULTS: Eighty-six patients were treated for post-SG GL. Forty patients (46.5%) had early-onset GL (postoperative day ≤ 7). Two patients (2.3%) presented primary gastrobronchial fistula. Fifty-six patients (70%) underwent immediate reoperation. Endoscopic treatment was required to treat the GL in 92.7% of the cases (n = 77). The mortality rate was 1.2% (n = 1). The treatment success rate was 89.1%. The median time to healing GL was 84 days (14-423 d). Eighty percent of the GLs had healed 120 days after discovery. After 120 days, the incidence of complications related to GL increased and few additional GLs healed. The only identified risk factor for treatment failure was large retained gastric fundus (P ≤ .05). CONCLUSIONS: Most cases of GL can be adequately treated by incorporating endoscopic stenting. Surgery for persistent GL should be performed within 120 days of discovery; after this cut-off, the incidence of GL-related complications increases. Large retained gastric fundus is a risk factor for treatment failure and may prompt the surgeon to consider earlier reoperation.