Aug. 16, 2019
Surgical interventions involving the gastrointestinal (GI) tract, especially in high-risk patients, are associated with a high rate of complications. Age, smoking, obesity and other comorbidities put patients at increased risk of developing post-surgical complications such as anastomotic leaks, fistulas or loss of gut continuity.
These complications can lead to prolonged hospitalizations, a mortality rate of up to 10% and an approximately tenfold increase in cost of care. The estimated cost of care to manage approximately 100,000 complications each year is about $10 billion. Existing management strategies for these complications, such as wait and watch or rescue surgery, have relatively low success rates, with less than 50% proving effective at a 30-day follow-up.
Mayo Clinic interventional endoscopists perform a variety of services to address some of the challenges associated with managing high-risk patients and to help improve outcomes in this population. In the hands of experienced practitioners, endoscopic strategies can help reduce the risk of complications by reducing the need for surgery, prevent high-risk rescue surgeries, shorten lengths of stay, improve quality of life and reduce overall costs.
At Mayo Clinic's campus in Rochester, Minnesota, a group of interventional endoscopists led by gastroenterologist Navtej (Nav) S. Buttar, M.D., have developed a specialized endoscopic intervention team (SE-IT) to address the unique needs of the high-risk patient population. Since its inception in 2015, the SE-IT has performed about 1,500 procedures annually. Dr. Buttar also serves as chair of the endoscopy practice and as director of complex endoscopy at the Rochester campus.
The list of services that the SE-IT provides for high-risk patients currently includes:
- Bariatric endoscopy, performed preoperatively for weight optimization in patients undergoing transplants and joint replacements, including gastric balloon, gastric sleeve, transoral outlet reduction and duodenal diversion procedures
- Minimally invasive endoscopic alternatives to GI surgeries, including resections (mucosal, submucosal and full thickness) for pre-malignant and early cancers; and endoscopic myotomy (POEM and G-POEM) for patients with achalasia and gastroparesis
- Endoscopic repair for patients experiencing postoperative complications such as fistula or leaks, to help improve nutritional status, preserve tissue integrity and mitigate inflammatory processes
Building on their clinical experiences in this field, Dr. Buttar and colleagues recently conducted a comprehensive examination of patient outcomes associated with endoscopic management of gastrointestinal defects such as fistulas, anastomotic leaks and perforations in more than 200 patients.
The Mayo team examined a prospectively maintained endoscopy database and identified 220 consecutive patients who underwent endoscopic treatment for GI defects from October 2010 to December 2015. Researchers noted patient age and gender, the location and type of lesion, the endoscopic device used to treat the lesion, whether the endoscopic therapy resolved the defect without need for surgery or served as a bridge to surgery, and any comorbidities and complications.
From the initial pool of 220 patients, five patients were lost to follow-up and nine to technical failures. Among the remaining 206 patients, 148 (71.8%) had fistulas, 16 (7.8%) had leaks and 42 (20.4%) had perforations. The average duration of follow-up was 183 days. The data analysis yielded several interesting results, which were published in Gastrointestinal Endoscopy and in Gastroenterology in 2016.
Endoscopic response overall
- 63.1% of patients who were managed endoscopically achieved complete success without surgery.
- 87.9% of patients who were managed endoscopically did not require surgery for at least 30 days.
- 35.9% of patients who were managed endoscopically were discharged from the hospital after index endoscopy.
- 9.2% of patients who were managed endoscopically were able to switch from TPN to oral nutrition.
- 13.1% of patients underwent endoscopy as a bridge to surgery.
- Most patients (79.2%) required two or less endoscopies to achieve complete resolution of fistulas, leaks or perforations.
Defect-specific endoscopic response
- A higher percentage of patients with upper GI defects were healed endoscopically compared with those with lower GI defects (72.9% vs. 47.9%, p = 0.001).
- A higher percentage of patients with acute GI defects were healed endoscopically compared with patients with chronic GI defects (69.2% vs. 52.4%, p = 0.02). Acute defects were defined as those in which endoscopy was performed ≤30 days from the diagnosis.
- A higher percentage of patients with perforations or leaks were healed endoscopically compared with patients with fistulas (82.8% vs. 56.8%, p = 0.001).
Rescue surgery response
- 16.0% of patients who underwent rescue surgery did not achieve success despite all endoscopic or surgical interventions.
- Endoscopic repair was associated with minor complications such as migration of over-the-scope clips in 4% of patients, and only one patient (0.5%) required emergency surgery.
"This research and our clinical experience at Mayo Clinic indicate that novel endoscopic therapies offer effective modalities for averting the need for surgery and for managing patients with gastrointestinal defects," explains Dr. Buttar. "Endoscopy can be used as a definitive strategy or to optimize patients for surgery. Early endoscopic intervention is key when managing patients with GI defects, and we are analyzing the economic impact of this innovative approach."
For more information
Muhammad Z, et al. Outcomes of endoscopic management of gastrointestinal defects: A large tertiary care center experience. Gastrointestinal Endoscopy. 2016;83:AB490.
Baruah A, et al. Outcomes of overstitch device in gastrointestinal repair, remodeling and anchoring: A large tertiary care center experience. Gastroenterology. 2016;150:S37.