Rectal perforations and fistulae secondary to a glycerin enema:Closure by over-the-scope-clip

Rectal perforations due to glycerin enemas(GE) typically occur when the patient is in a seated or lordotic standing position.Once the perforation occurs and peritonitis results,death is usually inevitable.We describe two cases of rectal perforation and fistula caused by a GE.An 88-year-old woman presented with a large rectal perforation and a fistula just after receiving a GE.Her case was further complicated by an abscess in the right rectal wall.The second patient was a 78-year-old woman who suffered from a rectovesical fistula after a GE.In both cases,we performed direct endoscopic abscess lavage with a saline solution and closed the fistula using an over-the-scope-clip(OTSC) procedure.These procedures resulted in dramatic improvement in both patients.Direct endoscopic lavage and OTSC closure are very useful for pararectal abscess lavage and fistula closure,respectively,in elderly patients who are in poor general condition.Our two cases are the first reports of the successful endoscopic closure of fistulae using double OTSCs after endoscopic lavage of the debris and an abscess of the rectum secondary to a GE.

Over-the-scope-clip closure of long lasting gastrocutaneous fistula after percutaneous endoscopic gastrostomy tube removal in immunocompromised patients:A single center case series

Over-the-scope-clips (OTSC®) have been shown to be an effective and safe endoscopic treatment option for the closure of gastrointestinal perforations, leakages and fistulae. Indications for endoscopic OTSC® treatment have grown in number and also include gastro cutaneous fistula (GCF) after percutaneous endoscopic gastrostomy (PEG) tube removal. Non-healing GCF is a rare complication after removal of PEG tubes and may especially develop in immunosuppressed patients with multiple comorbidities. There is growing evidence in the literature that OTSC® closure of GCF after PEG tube removal is emerging as an effective, simple and safe endoscopic treatment option. However current evidence is limited to the geriatric population and short standing GCF, while information on closure of long standing GCF after PEG tube removal in a younger population with significant comorbidities is lacking. In this retrospective single-center case-series we report on five patients undergoing OTSC® closure of chronic GCF after PEG tube removal. Four out of five patients were afflicted with long lasting, symptomatic fistulae. All five patients suffered from chronic disease associated with a catabolic metabolism (cystic fibrosis, chemotherapy for neoplasia, liver cirrhosis). The mean patient age was 43 years. The mean dwell time of PEG tubes in all five patients was 808 d. PEG tube dwell time was shortest in patient 5 (21 d). The mean duration from PEG tube removal to fistula closure in patients 1-4 was 360 d (range 144-850 d). The intervention was well tolerated by all patients and no adverse events occured. Successful immediate and long-term fistula closure was accomplished in all five patients. This single center case series is the first to show successful endoscopic OTSC® closure of long lasting GCF in five consecutive middle-aged patients with significant comorbidities. Endoscopic closure of chronic persistent GCF after PEG tube removal using an OTSC® was achieved in all patients with no immediate or long-term complications. OTSC® is a promising endoscopic treatment option for this condition with a potentially high immediate and long term success rate in patients with multiple comorbidities.

Perianal fistulodesis–A pilot study of a novel minimally invasive surgical and medical approach for closure of perianal fistulae

BACKGROUND Perianal fistulae strongly impact on quality of life of affected patients.AIM To challenge and novel minimally invasive treatment options are needed.METHODS Patients with Crohn’s disease(CD)in remission and patients without inflammatory bowel disease(non-IBD patients)were treated with fistulodesis,a method including curettage of fistula tract,flushing with acetylcysteine and doxycycline,Z-suture of the inner fistula opening,fibrin glue instillation,and Zsuture of the outer fistula opening followed by post-operative antibiotic prophylaxis with ciprofloxacin and metronidazole for two weeks.Patients with a maximum of 2 fistula openings and no clinical or endosonographic signs of a complicated fistula were included.The primary end point was fistula healing,defined as macroscopic and clinical fistula closure and lack of patient reported fistula symptoms at 24 wk.RESULTS Fistulodesis was performed in 17 non-IBD and 3 CD patients,with a total of 22 fistulae.After 24 wk,all fistulae were healed in 4 non-IBD and 2 CD patients(overall 30%)and fistula remained closed until the end of follow-up at 10-25 mo.In a secondary per-fistula analysis,7 out of 22 fistulae(32%)were closed.Perianal disease activity index(PDAI)improved in patients with fistula healing.Low PDAI was associated with favorable outcome(P=0.0013).No serious adverse events were observed.CONCLUSION Fistulodesis is feasible and safe for perianal fistula closure.Overall success rates is at 30%comparable to other similar techniques.A trend for better outcomes in patients with low PDAI needs to be confirmed.

Clinical efficacy of the over-the-scope clip device: A systematic review

BACKGROUND The over-the-scope clip(OTSC)system has been increasingly utilized as a nonsurgical option to endoscopically manage refractory gastrointestinal(GI)hemorrhage,perforations/luminal defects and fistulas.Limited data exist evaluating the efficacy and safety of OTSC.AIM To determine the clinical success and adverse event(AE)rates of OTSC across all GI indications.METHODS A PubMed search was conducted for eligible articles describing the application of the OTSC system for any indication in the GI tract.Any article or case series reporting data for less than 5 total patients was excluded.The primary outcome was the rate of clinical success.Secondary outcomes included:Technical success rate,OTSC-related AE rate and requirement for surgical intervention despite-OTSC placement.Pooled rates(per-indication and overall)were calculated as the number of patients with the event of interest divided by the total number of patients.RESULTS A total of 85 articles met our inclusion criteria(n=3025 patients).OTSC was successfully deployed in 94.4%of patients(n=2856/3025).The overall rate of clinical success(all indications)was 78.4%(n=2371/3025).Per-indication clinical success rates were as follows:(1)86.0%(1120/1303)for GI hemorrhage;(2)85.3%(399/468)for perforation;(3)55.8%(347/622)for fistulae;(4)72.6%(284/391)for anastomotic leaks;(5)92.8%(205/221)for defect closure following endoscopic resection(e.g.,following endoscopic mucosal resection or endoscopic submucosal dissection);and(6)80.0%(16/20)for stent fixation.AE’s related to the deployment of OTSC were only reported in 64 of 85 studies(n=1942 patients),with an overall AE rate of 2.1%(n=40/1942).Salvage surgical intervention was required in 4.7%of patients(n=143/3025).CONCLUSION This systematic review demonstrates that the OTSC system is a safe and effective endoscopic therapy to manage GI hemorrhage,perforations,anastomotic leaks,defects created by endoscopic resections and for stent fixation.Clinical success in fistula management appears limited.Further studies,including randomized controlled trials comparing OTSC with conventional and/or surgical therapies,are needed to determine which indication(s)are the most effective for its use.