Endoscopic management for gastrointestinal leaks, perforations, and fistulae: Technical tips and outcomes

Abstract

Gastrointestinal (GI) tract defects can be classified into three distinct entities: Leak, perforation, and fistula. Each arises from different mechanisms and is managed accordingly. Leaks occur most often after surgery, while perforations arise due to flexible endoscopic maneuvers. Fistulae arise from a variety of mechanisms, including specific disease states. Endoscopic management is vital in treating such defects if the region of interest can be accessed with the appropriate endoscopic accessories. The primary goal of endoscopic therapy is to interrupt the flow of luminal contents across a GI defect. Considering the proper endoscopic approach to luminal closure, several basic principles must be considered. Outcomes are dependent on the size and exact location of the leak/fistula, as well as the viability of the surrounding tissue. Almost all complex leaks and fistulae must be approached in a multidisciplinary manner, collaborating with colleagues in nutrition, radiology, and surgery. With advances in technology, a myriad of devices and accessories are available that allow a tailored approach. In this review, we discuss these modalities, provide technical tips, and review published outcomes data regarding each approach, as well as practical considerations for the successful closure of these defects.

Keywords: Leak; Clip; Metal stent; Endoscopy; Surgery; Iatrogenic

Core Tip: This review comprehensively explores the endoscopic modalities for managing gastrointestinal (GI) tract defects like anastomotic leaks, perforations, and fistulae. The main highlights of this review are various endoscopic modalities like endoscopic clipping, endoscopic stenting, endoscopic suturing, endoscopic vacuum therapy, tissue sealants, endoscopic internal drainage, and novel device-assisted closure methods for management of these defects. We specifically emphasize application techniques and tricks of various endoscopic devices and their clinical outcomes in patients with GI tract defects.