Managementul endoscopic al fistulelor de anastomoza post neoplasm esofagian și gastric operat

Abstract

Introducere: In pofida multiplelor progrese efectuate in chirurgia oncologica si endoscopica digestiva interventionala, fistulele de anastomoza esofagiana continua sa ramana unele dintre cele mai severe complicatii ale neoplasmului esofagian si gastric operat. Noile metode terapeutice endoscopice duc la cresterea ratei de inchidere a fistulelor de anastomoza esofagiana. Dintre acestea amintim: sten-turile esofagiene autoexpandabile, montarea de clipuri OTSC, terapie vaccum, VacStent, stenturile plastic dublu pigtail. Materiale si metode: Decizia de management endoscopic al unei fistule de anastomoza esofagiana este luata in functie de cateva criterii: marimea fistulei, prezenta colectiilor, localizarea fistulei de anas-tomoza esofagiana. Prezentam 4 cazuri de fistula de anastomoza esofagiana, dintre care 2 cazuri post neoplasm esofagian operat si 2 cazuri post neoplasm gastric operat, la care managementul endoscop-ic minim invaziv a permis inchiderea completa fistulei de anasatomoza esofagaiana. Au fost utilizate multiple metode de tratament interventional: montarea de stenturi esofagiene totatl acoperite, sten-turi dublu pigtail, terapie vaccum si clipuri OTSC ( clipuri over the scope). Rezultate: Evolutiile dupa diferitele metode de tratament endoscopic au fost favorabile, cu inchidrea completa a fistulelor, fara recidive. Complicatiile aparute dupa diferitele metode de tratament endoscopic, cat si rata de succes in inchiderea fistulelor de anastomoza esofagiana, au fost intotdeauna un motiv de reflectie pentru medicii endoscopisti, inainte de a lua decizia terapeutica adecvata in functie de particularitatile cazului. Concluzii: Consideram ca utilizarea selectiva si alegerea corecta a diferitelor metode de tratament endoscopic in managementul fistulelor de anastomoza esofagiana ofera pacientului cele mai mari sanse atat de solutionare a acestei complicatii, cat si de supravietuire.

Introduction: Despite the multiple advances made in oncological and endoscopic interventional digestive surgery, esophageal anastomotic fistulas continue to remain some of the most severe complications of operated esophageal and gastric neoplasms. The new endoscopic therapeutic methods lead to an increase in the rate of closure of esophageal anastomotic fistulas. Among these we mention: self-expandable esophageal stents, OTSC clip mounting, vaccum therapy, VacStent, double pigtail plastic stents. Materials and methods: The decision of endoscopic management for an esophageal anastomotic fistula is taken according to several criteria: the size of the fistula, the presence of collections, the location of the esophageal anastomotic fistula. We present 4 cases of esophageal anastomotic fistulas, of which 2 cases illustrate complications of operated esophageal neoplasm and 2 cases illustrate complications after operated gastric neoplasm. In all of the before mentioned cases minimally invasive endoscopic management allowed complete closure of the esophageal anastomotic fistulas. Multiple interventional treatment methods were used: fitting of fully covered esophageal stents, double pigtail stents, vacuum therapy and OTSC clips (over the scope clips). Results: The evolution of these patients after the different endoscopic treatment methods was favorable, with complete closure of the fistulas, without relapses. The complications arising after the different methods of endoscopic treatment, as well as the success rate in closing esophageal anastomotic fistulas, have always been a reason for reflection among endoscopists, before making the appropriate therapeutic decision according to the particularities of the case. Conclusions: We believe that the selective use and the correct choice of different endoscopic treat-ment methods in the management of esophageal anastomotic fistulas offer the patient the best chances for both solving this complication and also for surviving.