Endoscopic submucosal dissection combined with endoscopic closure of gastrointestinal fistulas, including those refractory to prior treatment: results after descriptive series.

Abstract

Background and aims: Several endoscopic techniques are available for the closure of fistulas but reported long-term efficacy is disappointing. Endoscopic submucosal dissection (ESD) combined with endoscopic closure showed promising results. We evaluated the results of this combined technique in a larger number of consecutive patients.

Methods: Patients with gastrointestinal fistulas, including those with previous failed treatment, were retrospectively included. During the procedure, injection and circumferential incision around the fistulous hole was performed, followed by dissection of the fistulous track as deep as possible creating a mucosal flap. The flap was finally removed and the edges closed using several closure devices. The primary outcome was long-term (> 3 months) success of fistula healing. Secondary outcomes included technical success, safety, and factors associated with success. To evaluate risk factors for long-term failure, patients treated in our previous descriptive study were included in the univariable analysis.

Results: We included 32 patients (66% refractory) in the present study. Technical success was 78%. 28/32 (88%) completed > 3 months follow-up. Among them, 43% (12/28) achieved long-term closure with 8 months median follow-up (interquartile range 5-18). In naïve patients, technical success rate was 91% (10/11) and long-term closure was 78% (7/9). Adverse events occurred in 3 patients (9%). Risk factors for long-term failure were evaluated in 51 patients (23 previously treated in our first descriptive study and 28 patients with complete follow-up from the present evaluation). Age (p = 0.01), surgical (p = 0.007) or oncological origin (p = 0.001) and previous treatment attempts (p = 0.007) were significantly associated to failure.

Conclusion: ESD with closure is safe and effective to cure fistulas, and could be considered part of the first-line treatment for naïve patients. In refractory patients, although of moderate efficacy, this technique could represent an alternative approach prior to salvage surgery.