Endoscopic treatment of postoperative fistulas resistant to conservative management using biological fibrin glue.

BACKGROUND AND STUDY AIMS: Postoperative fistulae occur frequently in standard surgical practice, but there is no general agreement on how to treat them. We summarize here our experience with endoscopic treatment.

PATIENTS AND METHODS: Postoperative digestive fistulae resistant to conservative treatment, in 15 patients, are retrospectively reviewed. Our series included two internal fistulas: (one rectovesical, and one high-output pleuroesophagic), and 13 external fistulas (one low-output gastrocutaneous, two low-output esophagocutaneous, seven low-output enterocutaneous, and three high-output enterocutaneous). After failure of conservative treatment, the fistulas were endoscopically located and 2 - 4 ml of reconstituted fibrin glue, Tissucol 2.0 at 37 degrees C, was injected through a catheter.

RESULTS: The mean age of the patients was 61.2 years (38 - 86), and 60 % were men. Of the fistulas, 26.6 % were of the high-output type. The mean healing time was 16 days (5 - 40), and a mean of 2.5 sessions per patient were required (1 - 5). Complete sealing of fistulas was achieved in 86.6 % of cases; (87.5 % of the low-output and internal fistulas, and 55 % of the high-output fistulas). After follow-up ranging between 2 months and more than 3 years, only one of the sealed fistulas reopened. No complications were encountered. Overall mortality was 13.3 % (two out of 15), but in only one patient was this related to clinical deterioration because of the persistence of the fistula.

CONCLUSIONS: We think that conservative treatment should not be prolonged beyond 14 days and that endoscopic treatment should be performed at that stage. Endoscopic sealing treatment achieves a very high success rate, without complications and at a lower cost. It could probably reduce the hospital stay, and avoid some unnecessary surgical interventions. Appropriate multicenter randomized trials are needed to confirm these results.