OVER-THE-SCOPE CLIP MANAGEMENT OF NON-ACUTE, FULL-THICKNESS GASTROINTESTINAL DEFECTS: A SYSTEMATIC REVIEW AND META-ANALYSIS
David Morrell*1, Christopher Hollenbeak2, Eric Pauli1
1Penn State Health Milton S. Hershey Medical Center, Hershey, PA; 2The Pennsylvania State University, University Park, PA
Introduction
Endoscopic strategies to manage non-acute, full-thickness gastrointestinal defects (FTGID) have become a promising alternative to surgical intervention. Use of over-the-scope clips (OTSC) to manage these defects has been studied in multiple case series with wide ranging outcomes in reported effective management via this endoscopic modality. This meta-analysis investigates the use of OTSC to manage non-acute FTGID.
Methods
A systematic review was performed by searching MEDLINE and the Cochrane Library for all studies reporting outcomes of over-the-scope clips in the management of non-acute FTGID. Non-acute FTGID was defined as full-thickness GI defects presenting for management greater than 24 hours after defect formation. Successful management was defined as radiologic or clinical evidence of complete defect closure at the conclusion of the follow-up period. Studies in which the OTSC system was not the primary treatment modality were excluded. A meta-analysis using a general variance-based approach was used to pool the results of these studies. The DerSimonian-Laird random effects model was used for pooled analysis with significant heterogeneity. Otherwise the Mantel-Haenszel fixed-effects model was used to pool the results.
Results
Forty-three studies including 691 patients were included in the pooled analysis. In these studies, 227 defects were classified as originating in the foregut and 67 in the hindgut. The most common defects were gastrocutaneous fistulae (74), enterocutaneous fistulae (45), gastrogastric fistulae (39), and gastric sleeve leaks (29). Successful management of non-acute, full-thickness GI defects with OTSC was 67% (95% CI: 59-75%; Figure 1). In a subgroup analysis of fistulas, 32 studies with 410 patients were included in the pooled analysis. The percentage of fistula patients successfully managed was 52% (95% CI: 47-57%). In a subgroup analysis of leaks, 20 studies with 210 patients were included; successful management was achieved in 77% (95% CI 71-82%).
Conclusions
Use of OTSC represents a promising endoscopic treatment modality for non-acute FTGID with a relatively high rate of successful management in a typically difficult to manage patient population. OTSC can be employed with a high expected rate of effectiveness as an alternative to potentially morbid surgical interventions to address these defects.
Forest plot from meta-analysis of successful management of non-acute, full-thickness gastrointestinal defects with over-the-scope clips.
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