Treatment of foregut fistula with biologic plugs.

Introduction: Enteric fistulas are a recognised complication of various diseases and surgical interventions. Non-operative medical management will result in closure of 60-70% of all fistulas over a six- to eight-week period, those that fail non-operative management will require operative intervention if they are to close. We present a series of upper gastrointestinal fistula managed with endoscopic intervention and insertion of biological fistula plug over a 3-year period across three Hospitals, both public and private, in Western Australia.

Methods: Over a three-year period, 14 patients were referred for treatment of acute or persistent foregut fistulas. All fistulas were managed with endoscopic intervention and insertion of a porcine small intestine sub-mucosa plug (Biodesign (®) Cook medical Inc., Bloomington, IN, USA). No patients with fistula were excluded. Data were collected on patient demographics and underlying diagnosis. The biological plugs were deployed using three different endoscopic techniques (direct deployment via the endoscope, catheter-assisted endoscopic deployment, or a pull through via a guide wire using a rendezvous technique).

Results: Fourteen patients with foregut fistula were treated using biological plugs. The age of the fistulas treated ranged from 14 days to 3 years. The fistulas were predominantly gastric in origin (eight cases). Three oesophageal, one gastro-pleural-bronchial, and two jejunal fistulas were also managed using this technique. Of the 14 fistulas treated using this method, 13 resolved following the treatment. Median time to closure of the fistula was 2 days (range 1-120 days). Three patients required more than one intervention to complete closure.

Conclusion: Biological plugs offer a further option for management of the traditionally difficult foregut fistula, without major morbidity associated with other treatment modalities. It is limited to the ability to deploy the plug endoscopically.