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 37degreesC, 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-out-put 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.