My next speaker or next speaker is also a friend of mine and a former colleague at the Cleveland Clinic. Now, Dr. Kocher is the Associate Chief of the Gastroenterology in Allegheny Health Network. And Dr. Kocher is also the current chair of the ASG's Special Interest Group in Interventional IBD. And Dr. Kocher's presentation is in the Scalp Care Management of the IBD Fistula, Clipped or Cut? Simran, the platform is yours. So good morning, everyone, and good evening if you're joining us internationally. I am Simran Kocher from Allegheny Health Network. I would like to thank the organizers and especially ASG for giving us this platform and opportunity to showcase interventional IBD. As Dr. Shen mentioned, I'm the chair of the ASG SIG for interventional IBD, and this is very exciting for us to have this platform. So today, I'm going to briefly talk to you about endoscopic management of IBD fistulas. So the learning objectives of my talk are what are the current advances in the management of fistulas? What is the specific technique of endoscopic fistula that Dr. Shen was mentioning, and what are the advances in management of leaks and abscess? These are my financial disclosures. So complications of IBD, and you probably have heard from authors before me, we mainly divide for our purposes into five groups, stricture, fistula, abscess, sinus, and intestinal leak. In the last floor, fistula, abscess, sinus, and intestinal leak can be clubbed together. So fistulas in IBD can affect up to 50% of patients with Crohn's disease. Perianal fistulas are the most common. Enteroenteric are more common than retrovaginal after the perianal fistulas. It is one of the hardest disease phenotypes to treat in all three modalities. The pathogenesis of fistula, there are various theories proposed. One is the epithelial to the mesenchymal transition of the cells, the activation of the matrix metalloproteinases, and then the cytokine theory. Genetics has also been blamed. There are more than 200 genetic pleomorphisms that have been identified. But for us clinically, I think the most common and important pathogenesis is the stricture formation. And this image correctly depicts this. You have a stricture, there is narrow stream, there is back pressure, and that leads to fistula and abscess formation. The role of mesentery has also been brought into play as to causing inflammation in fistulas. So management of fistulas, I just want to give you a broad overview here that surgery and medicine still remain the mainstays, and endoscopic therapy is evolving. It's an adjunct as of now to our surgical techniques and medical techniques. So various options have been tried for endoscopic management of fistulas. There has been endoscopic injection of fibrin glue and plugs. Stem cells are currently under clinical trial protocols being used. Stent and seton placement surgically has been a long stay of the management. EUS guided drainages, endoscopic clipping, suturing has been attempted, and fistulotomy. We'll start very briefly with the fibrin glue. It is simple. It's just a simple It is simple. It can be performed multiple times. There have been case series and retrospective studies that demonstrate more than 50% success rate of fistula closure in short-term. However, the long-term outcomes have not been very encouraging. Moving on to the clips, Dr. Shen already showed you. Full disclosure, I do not have any conflict of interest with any company, but these are various types of clips that are available in the market. I might have missed a couple here, but there are through the scope clips and over the scope clip that you can use if you can identify the fistulas opening. The advantages of through the scope clips is they're easy to use. They have high technical success rate at the time of the procedure, but they have a high failure rate because the clips fall off. There is issue with tissue grasping, especially when there is inflammation. The intestinal peristaltic activity results in clip migration. The other issue is if the fistulas have been chronic and the tract is fully epithelialized, then closing of these tracts is also difficult with the help of the clips alone. So I'm going to segue from that brief introduction with clips and fibrin due to endoscopic fistula artemy. So basically, this is a technique in which you use an electro-incision knife, you incise the fistula tract open, and you help in complete drainage. Predominantly in my practice, I use it for simple fistulas which have short fistulas tracts. These are the various equipments available to us. Again, full disclosure, I do not have any conflict of interest with any of these knives, but these are the most commonly knives that I use in my practice, be it fistula artemy, stricture artemy, things like that. I use the setting of Endocard Q323. That's a question I often get asked, so I just want to share that here up front. This is a graphical description of what we're going to talk about, how do we do endoscopic fistula artemy. Going back to the hypothesis of a stricture causing fistula, you can see very well here depicted, you have a stricture at the IC valve, tract pressure causes the fistula, you get a guide wire across, you do the stricture artemy part, you cut the stricture open, now the fistula has merged into the lumen. That is basically the concept of endoscopic fistula artemy. This is a patient, this is a video I'm going to share with you. This patient was sent to us with pouch inflammation. Give me one, yes, sorry, yes. I'm going to go back here. Yes, so this is a patient who has a J pouch, was sent to us because patient was having 14-15 bowel movements, although there was not much inflammation as you see in the pouch. A careful pouchoscopy showed that the patient had a fistula tract. We advanced the guide wire and then we decided to do endoscopic fistula artemy. In this case, I'm using an IT nano knife that ceramic tip does not conduct, and we are going to cut the fistula tract open so that it merges with the J pouch. We try to cut towards the lumen, not away towards the wall, that is more safer technique. As you see, there's a lot of tension on the fistula, so as we're cutting, it gets stretched open, and we continue to cut across the entire length of the fistula. The end result should be something like this. You've opened the fistula tract, it is now open completely. You use endoscopic clips to close the incised edges. In my opinion, it prevents delayed bleeding. Also, if there is any microperforation, as Dr. Shen was describing, you close that up. This next patient of ours also again has a J pouch, again having same issues of diarrhea on multiple biological medications. You look at the pouch itself, there is not much inflammation. He's already on biologics, but the problem is here. He has a thick septum and he has a pouch body-to-body fistula. As you can see, this is a very thick septum in the middle. We probe the wire through, and then we can see that the wire comes out as we are retroflexed. We then decide to do endoscopic fistula, in this case. It was a very thick septum. We initially started with using an IT knife, but you'll very quickly see here that IT knife was not able to cut too much of the tissue. Then we decided to switch to a needle knife. A needle knife is a commonly used tool in ERCP for pre-cut sphincterotomy. It is almost like a pure cut, conducts very well, but it can be a little detrimental to use if you don't have good control. As we were cutting the fistula here, there was a bleeding. I initially thought the bleeding will stop, as during most of our dissections, they do tend to stop, but this bleeding actually increased during the procedure. We then had to adopt certain rescue measures. We switched the knife out to quiet grasper, and we were able to control the bleeding with that. This is the concept of knowing your tools, knowing what to use when, and what tools can you go back on to. This was a very active bleed, so I don't think so. I also used D50 a lot because, you know, I was trained by Dr. Shen, but I felt in this case that might not have been helpful, so I used the quiet grasper. After being able to identify the vessel, we were able to stop it. We again then began the fistula cutting, but away from the initial vessel. The whole idea is to cut the complete septum open and make this into one tract so that you avoid fecal stasis. Patients can empty their pouch adequately because sometimes when people with J-pouch says they have diarrhea, it is not necessarily they are producing more stool. It might also be that they're having more trips to the bathroom because they're not able to completely evacuate for various reasons. So, it's very important to be aware of these things while we are taking care of these patients. And as you can see, the needle knife cuts very nicely. So, it has to be a very controlled cut because it can quickly get out of your hands. So, we proceed towards cutting this entire fistula, and for the interest of time, I can move the video along, but we are almost to the end, and in the end, we use clips, and you can see now it is one big opening. So, what has been our experience? This is a study that I did along with Dr. Shen at Cleveland Medical Center. I did along with Dr. Shen at Cleveland Clinic. We had 29 patients there in which we had attempted endoscopic fistulotomy, and it was successful in 26 patients. Three patients at the end of one year required surgery. One patient had a significant post-procedure bleeding for which the patient had to be hospitalized and required blood transfusion. So, in my opinion, endoscopic fistulotomy can be attempted in short, which is basically less than three centimeter fistulas, simple fistulas. Complex fistulas, you might not be very successful in doing this procedure. It can be used as an adjunct to your medical management and can be used in both primary and secondary fistulas. If you move on to the pigtail and C-term placement, this is actually a video by Dr. Shen. This was again from Cleveland Clinic, a patient. Sometimes if you see, and this goes back to his Friday theory. I mean, I actually scope all my patients on Friday because that's my scope day. But if you have a patient on the table and they have a perianal fistula, and you're in a practice where you don't have colorectal surgeons, this is a technique of placing endoscopic C-terms. You see a fistula's track here that's draining pus. You can see the pus coming out. You can pass a guide wire through that. You basically attach the C-term to the guide wire, and you just simply pull the guide wire across. You can then just get the C-term across the fistula's track right there. You can confirm this endoscopically. That is going through the track. This will help keep the track open and drain it well, and there'll be no pus formation. Now, the last step will be to apply the suture to keep the C-term in place. And that's endoscopic C-term placement. Moving on to the further complications, as we discussed, sinus or pouch sinuses, they are related to pouch tension and ischemia. Pouch sinus happens more in males than in females, and they sometimes can be managed with observation, but majority patients require either surgery or endoscopic therapy. Surgery, which includes de-roofing, is technically challenging, so it is not a simple procedure. That's where endoscopic sinusotomy can play a very important role. In this depiction, we are showing a sinus. Sinus is basically a track that has a blind end. It does not communicate with the other organ system just like a fistula does. The concept is still the same, that with the help of electroincision knife, we basically de-roof the sinus tract. Then we clean the cavity with hydrogen peroxide. You clip the edges, and after a while, as you see in picture C and D here, the C was endoscopic sinusotomy and D was the healed sinus tract. This picture actually is taken from Dr. Shen's book of pouchitis and pouch disorders. Very informative book for people interested in intervention. IBD should definitely consider having that on their library shelves. The initial published experience of sinusotomy, again, comes from the Cleveland Clinic group, from Dr. Shen's group. Treated 65 patients. All of them almost had anastomotic sinus. 28 achieved complete healing in single session. 27 had partial response. The good thing about endoscopic sinusotomy is that you can repeat the procedure. It's not like one and done and you can't repeat it. If the tract reforms or the tract is incompletely cut, or if you want to do it in a staged manner, you do, let's say a sinus is very long, five, seven centimeters, you want to cut three centimeters and then three centimeters, you can do that. Intracerebral leak, again, there is no definitive therapy. If you have an acute leak right after the surgery, then operative management is the best course at that time. Because if you have fresh anastomotic leak, because of the suture, there is edema and inflammation. Your clips, your endoscopic suturing might not be able to grasp the tissue as well. Those scenarios is helpful to send patients to back to the operating room. Self-expanding metal stents have been shown to help close leaks in post-op setting. Most of the data, again, I think comes from the bariatric surgeons, Ruh and Weigrup. IBD, the data is limited of using stent for leaks, especially in acute leaks. We have used actually over-the-scope clip, as I had shown you before, to treat leaks, especially the chronic leaks. We'll share two studies with you. The first one, we had patients with chronic tip of the J pouch leak. There were 13 patients in which we use the over-the-scope clip. It's very easy to put this over-the-scope clip and advance it to the blind end of the J pouch. You grab the blind end internally into the clip and then deploy the clip. In eight out of 13 patients, we were successful in closing the leak and avoiding the surgery at one year. At one year follow-up, eight out of 13 patients had no recurrence of the leaks. There were no complications observed from the procedure. How about the leak at the transverse staple line? Again, it's a post-op anatomy, but still, I think if people have chronic leak, which is common at the transverse staple sutures, usually patients require surgery, but we would again show that using over-the-scope clip, we can close these leaks. You basically challenge us to reach there with the Ovesco on the scope. Once you reach there, you have a guide wire in place. You can remove the guide wire and then deploy the clip on top of it. Again, we showed this in five patients and there was no need for surgery at the end of one year. Future tools. Again, for disclosure, I do not have any conflict of interest with these device companies, but there is an X-TAC suture system that is through the scope. You don't have to use over-the-scope suturing device or a 2D scope for this. It can go through your regular EGD and a colonoscope. I think this will help us to close leaks slightly better. The trick with this is that this is not a full thickness suture. It is a submucosal suture, so the results will have to be seen. Again, atrial septal device has been used again for fistulas in non-IBD setting predominantly, but I think the results are encouraging, so we might see that. Obviously, the stem cell trials that are ongoing are also an exciting avenue and we are all waiting for the results to see if they help in closing the fistulas. In our algorithm, and we had proposed this in our GI article as well, if you have an abnormal imaging or endoscopy that shows fistula and it's an asthmatic leak or distal bowel or short or shallow, or it's in the perianal region, you can consider fistula otomy. If there's an associated stricture, which usually happens, then do stricture otomy as well. Alone fistula otomy in that setting might not help. If it's a disease related or inflammatory or it is a rectovaginal fistula or a pouch vaginal fistula, then you have to optimize the medical therapy and most often they're not involved with surgical colleagues. In summary, endoscopic fistula management is rapidly evolving field. The need for less invasive and single orifice approach is growing, so definitely our technology is improving. Endoscopy technology in last 10 years has seen a lot of growth and so our tools are improving. I feel going forward, we'll have even more fistula management options than we currently do. Very important for anyone who wants to build not just a fistula practice, but interventional IBD practice to have a very sound knowledge of the anatomy and the disease state of IBD to understand the nuances, how Crohn's disease and ulcerative colitis and patients with pouch can behave. But in the beginning, target short, simple fistulas. Involve your surgical colleagues early because as Dr. Shen mentioned, if there was a complication or something like at least you have a plan B or a backup plan. So how to be involved more with the interventional IBD? So as I mentioned, I as a chair of the interventional IBDC would love to welcome all of our audience to be a part of this. This year we also have a hands-on session at DDW. Dr. Shen and I will be there to help you guys. So if anyone is interested to learn these techniques more, please join in. I have a very active social media presence. You can definitely follow me on there and we are soon about to possibly start a combined medical endoscopic IBD fellowship, a multi-center initiative. So more to come on that, but we want to welcome on everyone who wants to learn this and we have further SIG events planned for this year for interventional IBD. So stay tuned for that space. With that, I will end my presentation here. I apologize if I went slightly over time, but thank you so much again for inviting us. Thank you.

Dr. Simran Kocher

Gastroenterology

Endoscopic management

Fistulas

Inflammatory bowel disease (IBD)