Success of different closure modalities of gastrogastric or jejunal-gastric fistulas after EUS-directed transgastric intervention.
Academic Article
Overview
abstract
BACKGROUND AND AIMS: EUS-directed transgastric intervention (EDGI) involves the creation of a temporary tract between the gastric pouch or proximal jejunum and excluded stomach by deploying a lumen-apposing metal stent (LAMS) between the adjacent lumens. Once the intended intervention is completed, the LAMS is removed. Practices for closure of the resulting gastrogastric or jejunal-gastric fistula vary widely. The purpose of this study was to investigate the efficacy of different closure modalities. METHODS: This was a retrospective study across 6 different medical centers of patients who had undergone EDGI with subsequent LAMS removal. Patients without a follow-up study with either an upper GI series or repeat endoscopy to assess fistula closure were excluded. RESULTS: Of 106 included patients, 22 patients (21%) had persistent fistulas on follow-up study. Argon plasma coagulation (APC) combined with OverStitch (Boston Scientific, Marlborough, MA) was the most common modality used for fistula closure, with a persistent fistula found in 8 of 45 patients (17.8%). By comparison, a persistent fistula was found in 4 of 15 patients (26.7%) whose fistulas were not closed. APC combined with through-the-scope (TTS) clips had a high success rate in closing fistulas with a persistent fistula in 1 of 18 patients (5.6%). Patients with persistent fistulas had longer LAMS dwell times than those without fistulas (median, 100.5 days [IQR, 40-182.5] vs 30.5 days [IQR, 22-41.75], respectively; P < .001). When adjusting for LAMS dwell times, closures with APC + OverStitch, APC + TTS clips, or OverStitch were not associated with a decreased fistula rate compared with no closure. CONCLUSIONS: A long LAMS dwell time, independent of closure technique, is associated with a high rate of persistent fistula. Based on the available data, minimizing LAMS dwell times should be recommended after EDGI. Whether primary closure helps decrease the risk of persistent fistula needs further investigation.
