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Abstract

Endoscopic procedures and stent technology innovations have significantly developed their usage in gastrointestinal illnesses. The use of stents in the GI tract has expanded to encompass a wide range of malignant and benign diseases and anatomical sites. However, whether covered self-expanding stents can help control postoperative small bowel leaks and fistulas is still not answered. Stent's utility in managing bowel leaks and fistulas is rarely reported, and no adequate evidence in the literature concerning its benefits and limitations. A 63-year-old patient had numerous surgeries for recurrent adhesive intestinal obstruction. The patient repeated laparotomies were complicated with multiple minor bowel injuries, high output complex enterocutaneous fistulas, extensive leaks, nutritional depletion, and major wound and skin breakdown. This report describes our approach for deploying covered self-expanding metallic stents (SEMS) in the small bowel to manage high output complex enterocutaneous fistulas in this patient. The clinical benefits and drawbacks of such clinical applications are described, and the problems and difficulties experienced.
Palestinian Medical and Pharmaceutical Journal (PMPJ). 2022; 7(1): 00-00
The Utility of Covered Self Expanding Metal Stents in the Management of Complex Small
Bowel Fistula
Khaled Demyati1,*; Wael Sadaqa2; Iyad Maqboul1 & Alaa Rustom1
1Department of Surgery, An-Najah National University Hospital, An-Najah National University,
Nablus, Palestine. 2Department of Surgery, An-Najah National University Hospital, An-Najah
National University, Nablus, Palestine
*Corresponding author: khaleddemyati@najah.edu
Received: (28/9/2020), Accepted: (18/9/2021)
Abstract
Endoscopic procedures and stent technology innovations have significantly developed their us-
age in gastrointestinal illnesses. The use of stents in the GI tract has expanded to encompass a wide
range of malignant and benign diseases and anatomical sites. However, whether covered self-ex-
panding stents can help control postoperative small bowel leaks and fistulas is still not answered.
Stent's utility in managing bowel leaks and fistulas is rarely reported, and no adequate evidence in
the literature concerning its benefits and limitations. A 63-year-old patient had numerous surgeries
for recurrent adhesive intestinal obstruction. The patient repeated laparotomies were complicated
with multiple minor bowel injuries, high output complex enterocutaneous fistulas, extensive leaks,
nutritional depletion, and major wound and skin breakdown. This report describes our approach for
deploying covered self-expanding metallic stents (SEMS) in the small bowel to manage high output
complex enterocutaneous fistulas in this patient. The clinical benefits and drawbacks of such clinical
applications are described, and the problems and difficulties experienced.
Keywords: Covered Self Expanding Metal Stents, Stent, Complex, Small Bowel Fistula.
INTRODUCTION
Postoperative complications of enteral
leaks and fistulas are significant morbidity
and mortality. The management of these com-
plications can be very challenging, especially
in patients with multiple enteral fistulas with
high output. Furthermore, these patients usu-
ally require prolonged hospitalization with
wound care, nutritional support, sepsis con-
trol, and medical management before these
fistulas can heal or surgical reconstruction can
be performed. In such cases, the high output
of succus, which can be acidic or alkali, rich
in digestive juice, can further complicate pa-
tient care and cause severe skin excoriation
and significant fluid electrolytes disturb-
ancerecent advances in enteral stents design
and composition introduced novel usage and
indications. There is a wide array of endo-
scopic tools available to manage these compli-
cations to reduce mortality and morbidity and
decrease the length of hospitalization. While a
wide range of clinical applications of the
metal stent has been heavily described and
discussed in the literature [1, 2], their use in
managing small bowel high output fistulas has
been rarely reported [3]. This report describes
the utility of covered self-expanding metal
stents in managing such patients. We express
our technique in detail and discuss the prob-
lems faced and the targets achieved in a pa-
tient with an extreme case of multiple small
bowel fistulas with a deplorable medical con-
dition.
RESULTS
CASE REPORT
A 63-Year-old man had an old history of
perforated duodenal ulcer at the age of 35
(1985), for which he required laparotomy with
peritoneal lavage and Billroth II reconstruc-
tion. That surgery was complicated with re-
current adhesive small bowel obstruction for
which he had repeated laparotomy and release
of adhesions four times after that surgery
(1986, 2000, 2003, and 2005). The patient re-
quired small bowel resection twice in the
course of his illness. Recently, the patient was
admitted again to a district hospital with adhe-
sive bowel obstruction and a small bowel per-
foration. Surgery was performed at the same
hospital on February 9, 2018, with an emer-
gency laparotomy. The perforated segment of
the small bowel was resected, and primary
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anastomosis was performed. A few days later,
the patient has noticed a small bowel leak with
small bowel contents coming out of the lapa-
rotomy wound. CT scan was performed there
and showed the small bowel leaking through a
3cm track to the through the laparotomy
wound without intra-abdominal collections.
The patient was managed medically for
two weeks; however, the patient deteriorated
clinically and developed septicemia. Repeated
CT scans showed an intra- abdominal collec-
tion of 14 cm in the largest diameter. On
March 5, 2018, re-exploration was carried out.
Many small intestinal serosal rips and injuries
were discovered during this laparotomy and
mostly healed. This most recent operation was
exacerbated by minor intestinal leakage, a
ruptured abdomen, and septicemia. The pa-
tient was sent to our clinic for additional treat-
ment at this point. On admission, the patient
was found to have an open abdomen with se-
vere inflammation and adhesion of fragile
bowel with a leak from multiple sites (Figure
1).
Figure (1): Major breakdown of the laparotomy wound. The small bowel loops seen in the wound
are very inflamed and densely adherent with multiple fistula openings.
The patient was resuscitated; laparostomy
wound care was initiated with sepsis control.
Total parenteral nutrition started, and nonop-
erative therapy continued initially to resolve
infection and inflammation and restore the
peritoneal cavity. Wound exploration showed
that the fistulas involved multiple bowel loops
from different levels, including the proximal
jejunum. In 3 months of medical management,
most small bowel fistulas closed spontane-
ously, and the laparostomy wound partially
closed. However, two large proximal fistulas
failed to recover and remained to leak large
volumes of succus rich in bile and pancreatic
juice. Drains, including suction drains and
dressing techniques, could not control these
fluids, causing severe skin excoriations and
severe fluid-electrolyte disturbances (Figure
2). Furthermore, the patient remained in criti-
cal condition with severe malnutrition recur-
rent septicemia with several multidrug-re-
sistant bacteria; most of these infections were
catheter-related. The abdomen was still hard
all over, indicating persistent inflammation.
Figure (2): large proximal fistulas failed to re-
cover with non-surgical therapy and remained
to leak bile and pancreatic secretions rich fluid
in large volumes.
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At this point, we decided to insert coverer
metal stents to bypass the remaining two large
enterocutaneous fistulas (ECFs), aiming to
help control soiling, relieve excoriation, re-
duce fluid loss, and resume oral feeding. We
used two large diameters (23 mm) partially
covered stents. The metal stents were con-
trolled with multiple bands before the intro-
ducing catheter was removed to allow the
stent from both sides from the fistula lumen.
Half of the metal stent was deployed in one
side of the fistulated jejunum, and rubber
bands controlled the rest to prevent it from ex-
pansion while being removed from the intro-
duction set. This stent part was introduced
manually to the other side of the fistulated je-
junum. We released the rubber bands after in-
serting the rest of the stent in its planned posi-
tion. Both stents were deployed successfully,
and their position was maintained by tagging
it to the skin by prolene sutures. This tagging
was performed to prevent stents migration
(Figure 3).
Figure (3): a) Two metal stents were deployed successfully, and their position was maintained by
tagging it to the skin by prolene sutures to prevent stents migration. b) Fluoroscopic image showing
the two metal stents in position after the successful deployment.
Both fistulas output reduced dramatically
in progress, and the patient was allowed to
drink fluids freely. Fluids and electrolytes dis-
turbances were reduced, sepsis attacks were
also reduced, oral feeding improved, and the
patient started to have regular well-formed
bowel motions. After one month of this man-
agement, the patient's condition was good
enough to tolerate surgery, and adequate time
was given for intra-abdominal inflammation
to recover. During the definite surgery, we re-
moved the two metal stents and resected the
fistulated segment of the jejunum. The small
bowel was anastomosed, and the abdomen
closed. The patient recovered well after this
surgery, discharged home one week after sur-
gery with good oral food intake and good
bowel motion. Over one year follow up as an
outpatient, the patient remained well and
gained his usual weight and physical activi-
ties.
DISCUSSION
Postoperative enteral leaks and fistulas
are severe and complex, potentially cata-
strophic postoperative complications with
high morbidity and mortality rates. Most (75
to 90%) ECFs are iatrogenic (postoperative or
post-procedural) [4]. Half of these are caused
by anastomotic leak or dehiscence, and half by
inadvertent enterotomy [5]. The diagnosis of
an ECF is usually made by visualizing the
drainage of succus from the operative incision
or a drain site. Alternatively, a fistula may
arise with an overt wound infection; enteric
contents are found upon opening the surgical
wound.
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The postsurgical abdomen after laparot-
omy has dense adhesions and a friable edem-
atous bowel. These changes after surgery
make reoperation difficult and increase the
chance of injuries and further complications.
The abdomen complicated by ECF and sepsis
after laparotomy shows a dense fibro-adhesive
reaction from ~10 days to 6 weeks or longer
[4]. Avoidance of reoperation at this time,
when possible, is imperative. Medical sup-
portive therapy with sepsis control and nutri-
tional support should be initiated to allow the
abdominal organs to recover. In the absence of
distal obstruction or other complicating fac-
tors such as inflammatory bowel disease, neo-
plasm in the fistula tract, foreign bodies in or
near the fistula tract, radiation enteritis, un-
treated infection, epithelialization of the tract,
or mucocutaneous continuity, most ECFs heal
spontaneously with conservative therapy, with
the majority close by 12 weeks [6-8].
For surgical management of non-healing
cases to be successful, the patient must be
medically and nutritionally optimized, and
these preoperative requirements may take sev-
eral months to fulfill. Furthermore, the medi-
cal management of these patients can be very
complex, especially in patients with high out-
put proximal fistulas, which makes maintain-
ing the patient's nutritional status and fluid-
electrolyte balance very challenging. In addi-
tion, in cases where the fistula is discovered
upon opening a midline wound for presumed
wound infection, as in our patient, the fistula
is already situated in a large, open abdominal
wound which significantly complicates the
management of the fistula effluent.
The fistula effluent can be acidic or alka-
line, depending on its origin, at high volume,
or with stasis on the skin; excoriation can oc-
cur very fast. Stoma appliances and other out-
put control techniques become more compli-
cated when the skin is raw, uncomfortable,
and weeping. Enzymes in the succus can di-
gest the abdominal wall and result in a large
wound with a fistula at its center. One of the
significant benefits of using the covered me-
tallic stents, in this case, was the better control
of the fistula effluent and skin excoriation re-
lief.
In this patient, no enteral feeding could
not be given. Furthermore, while most fistula
openings healed with nonoperative manage-
ment, two large fistulas remained with a high
output of proximal bowel content. This efflu-
ent is alkaline and rich in pancreatic enzymes,
causing persistent severe fluid electrolytes
disturbances and skin excoriation despite op-
timal care efforts. As the patient was still not
ready for surgical treatment, covered metallic
stents were utilized to control the succus leak.
Two large-diameter stents are used to manage
the remaining two large fistulas to temporarily
restore bowel continuity, allow oral feeding,
reduce fluid and electrolytes disturbances, and
reduce skin excoriations. Significant reduc-
tion of fistulas output allowed skin excoria-
tions to recover and made wound care and
fluid electrolytes management easier. The pa-
tient was allowed to drink nourishing fluids,
which improved his mood and helped build
his nutrition and rehabilitate his bowel. How-
ever, despite the benefits achieved, both fistu-
las failed to close. Eventually, surgery was
needed to resect the fistulated bowels and re-
store the bowel continuity. This surgery was
performed when the patient was medically
and nutritionally optimized, and adequate
time was given for intra-abdominal inflamma-
tion to recover.
A multidisciplinary approach to gastroin-
testinal leaks, including therapeutic endos-
copy, plays an essential role in management
by offering a minimally invasive modality of
tackling these problems. The clinical applica-
tions for endoluminal stent placement con-
tinue to expand and have become a versatile
and clinically beneficial tool along the entire
gastrointestinal tract. While it was initially
used to manage esophageal, gastroduodenal,
and malignant colonic obstruction, gastroin-
testinal stents' clinical indication expanded to
include endoscopic treatment of fistula and
leaks [2]. They are employed to close leaks
and fistulae to prevent extraluminal flow and
promote healing. SEMS successfully used for
esophageal perforation and anastomotic com-
plications, such as esophagojejunostomy leak
and stricture. Furthermore, covered
SEMSsfurther expanded to be used in differ-
ent settings like managing bariatric surgery
complications such as gastric sleeve leak and
Roux-en-Y gastric bypass anastomotic leak
and stricture and colorectal surgical complica-
tions.
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SEMS come in various lengths and diam-
eters, and most have a proximal and distal
flare to prevent migration. We used partially
covered metals stent to reduce stent migration
in this patient.
Endoscopic control of enterocutaneous
fistula has been described using different tech-
niques [3, 9-10], aiming to control fistula, op-
timize nutrition and optimize patients to help
them recover. Melich G et al. describe the con-
trol of enterocutaneous fistula by dual intus-
susception stent technique [3]. Melich G et
al.'s approaches involve inserting two covered
overlapping stents endoscopically, one proxi-
mal and one distal to the fistula, with 2 cm of
each stent protruding cutaneously. The proxi-
mal stent is crimped and intussuscepted into
the distal stent with an appropriate overlap.
Both stents were fixed to the abdominal wall
using a prolene suture passed through the an-
terior wall of both stents. We believe that the
technique described in this report is easy and
safe to use. The stents can be deployed percu-
taneously under fluoroscopic and or endo-
scopic control.
CONCLUSION
Large high-output enterocutaneous fistu-
las are complex life-threatening conditions
with great difficulties, especially in recent sur-
gery, nutritional depletion, and compromised
skin integrity. As shown in this report, the
covered self-expanding metal stents can help
control this type of fistulas, facilitate wound
care, nutritional support, sepsis control, and
medical management, optimizing intra-ab-
dominal and systemic conditions for substan-
tial surgical reconstruction.
Ethics approval and consent to participate
Our institution does not require ethical
approval for reporting individual cases or case
series.
Consent for publication
Written informed consent was obtained
from the patient(s) for their anonymized infor-
mation published in this article.
Author's contribution
Khaled Demyati: conceptualization, writ-
ing-original draft, data curation, formal analy-
sis, investigation, methodology, project ad-
ministration, resources, software, supervision,
validation, visualization, and writing review
& editing. Wael Sadaqa: writing review & ed-
iting. Iyad Maqboul: writing review & editing.
Alaa Rustom: writing review & editing.
COMPETING INTEREST
The author(s) declared no potential con-
flicts of interest concerning this article's re-
search, authorship, and publication.
FUNDING
The author(s) received no financial sup-
port for this article's research, authorship, and
publication.
ACKNOWLEDGMENTS
The authors are very thankful to the sur-
gical team, Intensive care team, radiology de-
partment team, and physiotherapy unit at our
hospital for providing support for completing
this report.
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IntroductionLarge high-output enterocutaneous fistulas pose great difficulties, especially in the setting of recent surgery and compromised skin integrity. Methods This video demonstrates a new technique of endoscopic control of enterocutaneous fistula by using two covered overlapping stents. In brief, the two stents are each inserted endoscopically, one proximal, and the other distal to the fistula with 2 cm of each stent protruding cutaneously. Following this, the proximal stent is crimped and intussuscepted into the distal stent with an adequate overlap. A prolene suture is passed through the anterior wall of both stents to prevent migration. The two stents used were evolution esophageal stents—10 cm long, fully covered, double-flared with non-flared and flared diameters being 20 and 25 mm, respectively (product number EVO-FC-20-25-10-E, Cook Medical, Bloomington, IN, USA). ResultsThe patient featured in this video developed a high-output enterocutaneous fistula proximal to a loop ileostomy, which was created following a small bowel leak after a curative surgery for bladder cancer. Using the technique featured in this video (schematic depicted in Fig. 1), the patient was nutritionally optimized with oral feeds from albumin of 0.9–3.4 g/dl within 2 months despite prior failure to achieve nutrition optimization and adequate skin protection with combination of oral and/or parenteral nutrition. Three months after stenting, following nutritional optimization and improvement of skin coverage, definitive procedure consisted of uncomplicated fistula resection with primary stapled side-to-side functional end-to-end anastomosis. The stents were not completely incorporated into the mucosa and were rather easily pulled through the residual fistula opening just prior to the surgery. Only minimal fibrosis was noted and less than 20 cm of involved small bowel needed to be resected. Had the fistula have closed completely, the options would have included (1) proceeding to bowel resection with removal of the stents regardless of closure, or (2) cutting the securing prolene stitch and observation. Considering the placement of the stents in mid-small bowel, their endoscopic retrieval would have been difficult unless they were to migrate into the colon. Conclusions Although a prior attempt at managing an enterocutaneous fistula with a stent deployed through a colostomy site was previously reported [1], there is no published account of bridging an enterocutaneous fistula with overlapping endoscopic stents through the fistula itself. This video serves as a proof of concept for temporizing enterocutaneous fistulas with endoscopic stenting.
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A post-bariatric surgery leak is a rare but grave condition and remains every bariatric surgeon's nightmare. Endoscopic therapy with the insertion of self-expandable stents provides an effective minimally invasive approach for the management of leaks. Self-expandable stents, however, are still hampered by their tendency for migration and are not always well tolerated. Recently, double-pigtail stents have been proposed as an alternative endoscopic therapeutic modality. Both types of stents have been shown to be very effective in the management of leaks; however, most studies have pooled gastrointestinal leaks due to different etiologies together. In this article, we review the current status and foreseen innovations in gastrointestinal stenting for post-bariatric surgery leaks.
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An enterocutaneous fistula (ECF) is a potentially catastrophic postoperative complication. Although the morbidity and mortality associated with ECF have decreased over the past 50 years with modern medical and surgical care, the overall mortality is still surprisingly high, up to 39% in recent literature. It seems prudent, then, for every surgeon to have a thorough grasp of optimal treatment strategies for ECF to minimize their patients' mortality. Ultimately, the algorithm must begin with prevention. Once an ECF is diagnosed, the first step is to resuscitate and treat sepsis. The second is to control fistula output. The third step is to optimize the patient medically and nutritionally. The last step is definitive restoration of gastrointestinal continuity when necessary. Special mention is given in this article to exceptionally refractory fistulas such as those arising in the presence of inflammatory bowel disease and irradiated bowel. This plan gives a framework for the difficult task of successfully treating the postoperative ECF with a multidisciplinary approach.
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Colocutaneous fistulas are frequently the result of complications related to previous operative procedures and are a major cause of morbidity. Most are initially treated conservatively, with a large percentage eventually requiring further surgery for definitive treatment. The use of a temporary colonic stent for the management of colostomy-related colocutaneous fistula has not been previously described. Two patients with colocutaneous fistula related to end colostomies and opening into midline laparotomy wounds were treated by temporary plastic stenting. A removable Polyflex silicone stent was inserted into the stoma. Stent redeployment was needed on several occasions following partial stent expulsion. Midline wound healing was achieved in both cases by 6 weeks post-stent insertion, and complete fistula closure occurred in 1 case. Temporary stent placement in certain cases may aid in the management of a colocutaneous fistula associated with a colostomy to allow fecal diversion from wounds and aid fistula closure.
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Enterocutaneous fistulas (ECFs) are a complex topic in terms of classification. ECF-related morbidity and mortality can be high due to fluid loss and electrolyte imbalance, sepsis, and malnutrition. Most prognostic factors influencing the outcome of ECF are now well-known. ECF treatment is complex; and, based on various situations, it can be surgical or conservative/ medical. Depending on fistula site and nutritional status, clinicians have to decide whether total parenteral or enteral nutrition should be established. In cases where total parenteral nutrition alone for 7 days has failed to influence the high output fistulas, overall data support the use of adjuvant drug, somatostatin, or its synthetic analogue, octreotide. Somatostatin 250 microg/d and octreotide 300-600 microg/d have been tried along with total parenteral nutrition to decrease the healing time of ECFs and to reduce the number of complications.
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To identify the causes of postoperative enterocutaneous fistulas and to evaluate the results of conservative and operative treatment including the effectiveness of octreotide in the management of these fistulas. A descriptive study. Department of Surgery, Liaquat University of Medical and Health Sciences, Jamshoro / Hyderabad between January 1997 and December 2001. Forty patients with postoperative fistula were studied. Demographic variables, causes and management outcome was observed and recorded. There were 25 males and 15 females with 50% of the patients being in age group of 21-30 years. Emergency surgery for typhoid perforation(45%) and intestinal tuberculosis (30%) were the commonest causes. Ileum and jejunum were the commonest sites of fistulation found in 85% cases. Twenty-one patients were started on conservative treatment with spontaneous closure occurring in 15 (71.4%) patients. Nineteen patients were operated within three days of admission due to generalized peritonitis (73.7%) and local intra-abdominal collections (26.3%). Wound infection was the commonest complication in the operative group. The mortality rate in this series was 7.5%. All the deaths occurred following surgery. Postoperative enterocutaneous fistula has a high morbidity and a significant mortality. Sepsis in the peritoneal cavity is the major cause of mortality. Conservative treatment has a good outcome for these fistulas. The use of octreotide is highly recommended as it definitely converts high output fistulas to low output fistulas.
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