This ASG video tip is sponsored by Braintree, maker of the newly approved Soufflave and Soutab. Principles of defect closure. There are four D's. You have to secure all four of them if you want to guarantee success. Drainage, diversion, diet, and then you must address distal obstruction. Drainage can come in a variety of ways. Percutaneous is most common. That's chest tube or mediastinal drain. Next come internal drainage. This can be double pigtail or endoscopic vacuum therapy, which is in some ways internal-external if you think about it. Diversion comes in the form of a stent. It also can come in the form of EVT. They make a U-turn. They swallow the secretions. They get sucked back out, as well as placing the patient NPO. Diet also has to be secured. So important, too. I often, on the index endoscopy, place a PEG-J tube, a direct PEJ, or acutely, if they're very ill, TPN. You also must address distal obstruction because oftentimes, hydrodynamically, that is the cause of the development of the fistula. There's a distal obstruction, so you can address that with a stent or a dilation. Notice that stent is listed there twice. EVT is also listed there twice. So some of the most common modalities address multiple Ds. If all four of these are addressed, success is maximized. You know what you notice there? There's no C for closure. There's Ds, but no C, no closure. Why is that? Ladies and gentlemen, if you secure the four Ds, you don't need to close. They will heal on their own. Now, obviously, if you close, you secure diversion, and you can reintroduce diet and so on. But you must secure these if you have any shot at closing a chronic fistula in particular. So notice the fully covered stent. It gets diversion, and it can resolve distal obstruction. Two birds with one stone. Diet, kind of. I don't feed them when they're on the stent, but you could put a Dobhoff tube down, for example. Endoscopic vacuum therapy, you both get drainage and you get diversion. Now you say, what do you mean diversion? Well, you just—the secretions make a U-turn. They just get suctioned out instead of getting bypassed like the stent. So I normally tell you to say this out loud, but there's too many people here. Say this. I see pus. I drain pus. Do not say this. I see hole. I close hole. If you see hole and you close hole, and it's soiled, I will come to your house and punch a hole in the drywall, take a dump behind the wall, and then patch it up. And we'll see how that goes. It's not going to go very well. So don't do that. And I know a lot of people in this room are advanced endoscopists. You want to manage everything on your own. But resist. This must be a multidisciplinary problem. And here's the reason. Mediastinitis is the pancreatitis of the chest. If you think pancreatitis is bad at creating a raging systemic inflammatory response, you haven't seen nothing yet. These people will die within 48 hours if you don't get the mediastinum source under control. So you have to drain the mediastinum. You must get a chest tube if the pleura has been compromised. The drainage of the pleural cavity, and I learned this the hard way, is not always equivalent to the drainage of the mediastinal cavity. Some patients only have mediastinal abscess. They haven't broken into the pleural space. Some people have broken through both. You drain the pleura with the chest tube. There's still a mediastinal abscess. So you may need both. Utilize CT scans very generously in the management of these patients to ensure no undrained connections or collections are left behind. I sometimes just use non-contrast, low-resolution studies.

chronic fistulas

defect closure

Drainage

Diversion

Diet