Endotherapy of leaks and fistula

Table 1 Etiology of gastrointestinal leaks and fistula

Diagnostic endoscopy including endoscopic ultrasound

Dilation: bougie, balloon, achalasia

Polypectomy/EMR/ESD

Foreign body

Endoscopic variceal therapy including ligation

POEM

Anastomotic dehiscence

Boerhaave’s syndrome

Diverticulitis

Laser

PEG

Endoscopic sphincterotomy

Biliary stent migration

Ampullectomy

Appendicular abscess

Empyema

EMR: Endoscopic mucosal resection; ESD: Endoscopic submucosal dissection; POEM: Peroral endoscopic myotomy; PEG: Percutaneous endoscopic gastrotomy.

Table 2 Causes of leaks and fistula

Leaks	Fistula
Iatrogenic (60%)	Malignant (50%)
Endoscopy	Benign
EVL	Stents
Dilatation	Tuberculosis
ESD/EMR	Crohn’s
POEM	Iatrogenic
Spontaneous	Trauma
Boerhaave’s	Surgical
Foreign body	AIDS
Surgical
Trauma

EVL: Endoscopic variceal ligation; EMR: Endoscopic mucosal resection; ESD: Endoscopic submucosal dissection; POEM: Peroral endoscopic myotomy; AIDS: Acquired immune deficiency syndrome.

Table 3 Endoscopic procedures in different parts of gastrointestinal tract associated with increased risk of iatrogenic perforation

Esophagus and stomach
Dilatation	ESD
EMR	Foreign body removal
POEM	EVL
Small bowel
Altered anatomy	DBE in altered anatomy
Dilatation in Crohn’s	ESD
Dilatation of GJ stricture after gastric bypass
Colon
EMR	Balloon dilatation
ESD	Old age, co-morbidity
Inexperience	Inflammatory colonic disease

ESD: Endoscopic submucosal dissection; EMR: Endoscopic mucosal resection; POEM: Peroral endoscopic myotomy; EVL: Endoscopic variceal ligation; DBE: Double-balloon; GJ: Gastrojejunostomy.

Table 4 Modalities for endotherapy of leaks/fistula

Closure

Endoclips

Suture

Sealant: Fibrin, cyanoacrylate

Diversion

Covered stents

Table 5 Result of endotherapy for iatrogenic esophageal perforation¹

Ref.	Type of treatment	Patients(n)	Technical success (%)	Complications(%)
2Freeman et al[43]	SEPS	19	100	24
Vallböhmer et al[44]	SEMS	12	100	8
2van Heel et al[45]	SEMS/ SEPS	31	100	33
Schimdt et al[46]	SEMS ± clip (1)	22	100	NA
Swinnen et al[47]	SEMS	23	100	NA
D’Cunha et al[48]	SEMS/ SEPS	15	95	13
Biancari et al[49],	Stents ± clip (1)	12	100	25
Schweigert et al[50]	SEMS/ SEPS	13	100	85
2Heits et al[51]	Vaccum therapy	10	100	20
Biancari et al[52]	SEMS/clip	67	100	34

¹Only studies with 10 or more patients have been included;

²Study design was prospective, rest were all retrospective. NA: Not available; OTSC: Over-the-scope clip; SEMS: Self-expandable metal stent; SEPS: Self expandable plastic stent.

Table 6 Result of endotherapy for iatrogenic gastric perforation

Ref.	n	Additional procedures	Success rate (%)
TTS
Tsunada et al[53]	7	Omental patch (1 case)	100
Fujishiro et al[39]	11	-	100
Minami et al[23]	121	> 1 cm: omental patch	98.3
Shi et al[54]	20	Endoloop	100
Zhong et al[55]	14	Endoloop	100
OTS
Kirschniak et al[24]	72	-	100
1Voermans et al[22]	6	-	100
Nishiyama et al[56]	7	-	86

Only studies with 5 or more patients are included.

¹All studies were retrospective except Voermans et al[22];

²13 OTS clips were placed in 7 patients.