Fistula repair with Apollo Overstitch - presentation DDW 2011

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Chris Thompson's early data on gastrogastric fistula repair presented @ DDW (Chicago, 2011)

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Fistula repair with Apollo Overstitch - presentation DDW 2011

  1. 1. BRIGHAM AND WOMEN’S HOSPITAL HARVARD MEDICAL SCHOOL Endoscopic Repair of Postoperative Gastrointestinal Fistulae Using a Novel Endoscopic Suturing Device: Technical Feasibility and SafetyRabindra R Watson, Pichamol Jirapinyo, Christopher C. Thompson
  2. 2. No DisclosuresRabindra R Watson, M.D. Division of Gastroenterology Brigham & Women’s Hospital Harvard Medical School Boston, MA, USA
  3. 3. Introduction: Background• Gastrointestinal fistulae (GF) complicate a variety of operations • Cancer operations • 0-46% of open gastric bypass • 1-6% of laparoscopic divided gastric bypass• Associated with morbidity, increased healthcare costs, prolonged hospitalization
  4. 4. Introduction: Background• Surgical repair of GF can be technically challenging due to adhesions and fibrosis • Morbidity up to 50% • Mortality 2%• Endoscopic therapy presents a less invasive alternative
  5. 5. Introduction: Endotherapy• Clips: • Endoclips – esophageal leaks, perforations • Over the scope clips • Limited by fibrosis, fistula size, durability
  6. 6. Introduction: Endotherapy• Injectable Agents • Fibrin Glue: • Thrombin + calcium + aponectin + fibrin = acellular clot • Cyanoacrylates
  7. 7. Introduction: Endotherapy• Stents: • Covered metal stents • Migration, tissue overgrowth • Anatomy
  8. 8. Introduction: Endotherapy• Endoscopic Suturing:
  9. 9. Introduction: Setting • Our institution is a large tertiary referral center for bariatric surgery and complications • Experience with endoscopic treatment of GF using a variety of techniques
  10. 10. Aim: To evaluate a novel endoscopic suturing device in the treatment ofgastrointestinal fistulae with respect to technical feasibility and safety
  11. 11. Introduction: Suturing Device Reproduced with permission by manufacturer
  12. 12. Methods: Argon Plasma Coagulation
  13. 13. Methods: Suturing
  14. 14. Methods: Fibrin Glue
  15. 15. Methods: Post-Procedure Care • All patients discharged on PPI • NPO day of procedure • Clear liquids  full liquids x 2 weeks • Liquid Tylenol for pain
  16. 16. Methods: • Technical Success: Intact deployment of suture across fistula os • Early complications (<48 hours) • Follow-up: radiography, endoscopy clinical
  17. 17. Patients: Time Interval Diameter Age Sex Operation Symptoms (mm) (mo) Patient 1 48 F LAR 5 8 Rectovaginal Fistula Patient 2 40 M RYGB 144 6 Weight regain Patient 3 70 M Esophagectomy 5 8 Mediastinitis Patient 4 58 F RYGB 6 20 Weight regain Patient 5 59 M RYGB 10 7 Weight regain Patient 6 55 F RYGB 34 5 Weight regain Patient 7 61 F RYGB 96 10 Weight regain 51.9 8.7±5.2
  18. 18. Results: # of Procedure Technical Success Sutures Length (min) Patient 1 1 25 Yes Patient 2 1 12 Yes Patient 3 1 30 Yes Patient 4 3 30 Yes Patient 5 1 60 Yes Patient 6 1 60 Yes Patient 7 1 9 Yes 1.3 36.1±19.6 100%
  19. 19. Results: Complications• No early complications• Post-procedure abdominal pain commonly reported, managed conservatively
  20. 20. Results: Follow-up Follow-up Operation Confirmation Outcome Interval (mo) Patient 1 6 LAR Barium Enema Failure Patient 2 6 RYGB Endoscopy No Sx, Weight Loss Patient 3 5 Esophagectomy Endoscopy Resolution Patient 4 5 RYGB Clinical No Sx, Weight Loss Patient 5 6 RYGB Clinical No Sx, Weight Loss Patient 6 5 RYGB Clinical No Sx, Weight Loss Patient 7 3 RYGB Clinical No Sx, Weight Loss 5.1
  21. 21. Results: Follow-up Follow-up Weight loss Operation Interval (mo) (pounds) Patient 2 6 RYGB 24 Patient 4 5 RYGB 22 Patient 5 6 RYGB 20 Patient 6 5 RYGB 27 Patient 7 3 RYGB 23 22.8±2.4 Pouch reduction?
  22. 22. Limitations• Single expert center experience• Small number of patients• Follow-up Interval
  23. 23. Conclusions• Endoscopic repair of various GF is technically feasible using this novel suturing device• Fistula repair can be achieved safely within a short procedure time• Further study is underway regarding durability and long-term success rates
  24. 24. BRIGHAM AND WOMEN’S HOSPITAL HARVARD MEDICAL SCHOOL Endoscopic Repair of Postoperative Gastrointestinal Fistulae Using a Novel Endoscopic Suturing Device: Technical Feasibility and SafetyRabindra R. Watson, Pichamol Jirapinyo, Christopher C. Thompson
  25. 25. Introduction: Suturing Device

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