Successful Therapy of Esophageal Fistulas by Endoscopic Injection of Emulsified Adipose Tissue Stromal Vascular Fraction

Esophageal fistula is a life-threatening condition caused by several types of injuries (iatrogenic, traumatic, postoperative, and Boerhaave syndrome), requiring complex multidisciplinary management. To date, no clear guidelines have been drawn up for the treatment, which may include conservative, minimally invasive, or major surgical approach (ie, esophagectomy), depending on patient’s specific clinical characteristics. The mortality rate exceeds 50%, particularly in case delayed diagnosis.1Brinster C.J. Singhal S. Lee L. et al.Evolving options management esophageal perforation.Ann Thorac Surg. 2004; 77: 1475-1483Abstract Full Text PDF PubMed Scopus (482) Google Scholar We present series fistulas (post-traumatic secondary to anastomotic dehiscence after esophagectomy cancer) successfully treated with an innovative local inexpensive endoscopic delivery stromal vascular fraction obtained mechanical emulsification autologous adipose tissue (tSVFem; widely used other medical fields different purposes) as recently described our group.2Porziella V. Nachira D. Boškoski I. al.Emulsified grafting: new frontier treatment fistulas.Gastrointest Endosc. 2020; 92: 1262-1263Abstract (1) From July 2019 January 2020, 12 patients were endoscopy and/or surgery. Of these, 5 nonconsecutive (3 females; 49.6 ± 14.5 years old) affected not responding unfit standard treatments (endoscopy surgery). Two upper esophagus (1 traumatic), 3 distal (2 syndrome 1 In 4 cases, stenting failed close weeks, whereas one it was excluded technical reasons owing localization (located hypopharynx high risk due comorbidities). mean diameter fistulous orifice 8 mm (range, 4–15 mm). All procedures approved institutional review board compassionate use treatments. procedure performed average 22 days 10–100 days) from onset team (endoscopists, thoracic, plastic surgeons). aim exploit regenerative capacities tSVFem harvested delivered locally (Supplementary Video 1). under general anesthesia orotracheal intubation. Approximately 30 mL fat superficial layer subcutaneous tissue2Porziella 2.1-mm microcannula four 1-mm holes (Trivisonno micro harvester cannula SuperLuer, Tulip Medical, San Diego, CA) harvest microfat. Then, 20 microfat sequential passages through filters (2.4 1.2 mm, Nanofat filter transfer set, Medical), 600/400 ?m disposable filtering device (NanoTranfer, Medical). tSVFem, comprising mesenchymal cells fragments extracellular matrix, collected centrifugation removal supernatant oil released upon mature adipocytes disruption. Subsequently, esophagoscopy inject 10 into (through 6F catheter) until completely filled. 22G needle, total 1–2 injected submucosa quadrants borders, obliterate completely. time 50 minutes. There intraprocedural postprocedural complications. fed parenteral nutrition 7 received empirical broad-spectrum antibiotic therapy. A radiologic control at day showed complete healing (Figures 2) all cases. Patients then allowed normal oral intake.Figure 2Complete resolution injection.View Large Image Figure ViewerDownload Hi-res image Download (PPT) follow-up months 6–12 months) done patients. At this time, reepithelized luminal strictures found. Clinically, asymptomatic follow-up. are often fragile, highly risky invasive. Less invasive such stenting, endoluminal vacuum therapy, suturing used,3Kuehn F. Loske G. Schiffmann al.Endoscopic therapy various defects gastrointestinal tract.Surg 2017; 31: 3449-3458Crossref (58) Scholar,4Brangewitz M. Voigtländer T. Helfritz F.A. closure intrathoracic leaks: stent versus vacuum-assisted closure, retrospective analysis.Endoscopy. 2013; 45: 433-438Crossref (123) but these require long hospitalization skilled operators without certain results rates As alternative, anti-inflammatory tissue–promoting effects safely promote rapid effective healing. Healing mechanisms chronic subverted favor inflammation fibrosis. Delivery promising that promotes virtue its immunosuppressive, immunomodulatory, proangiogenic, potentials.5Ceccarelli Pontecorvi P. Anastasiadou E. al.Immunomodulatory effect adipose-derived stem cells: cutting edge application.Front Cell Dev Biol. 8: 236Crossref (29) Because grafted material study autologous, there rejection. Fat grafting cell transplantation broadly applied outside surgery field,6Trivisonno A. Abecassis Monti al.Adipose tissue: energy reservoir source epithelial engineering.Stem aesthetic procedures. Springer, Berlin, Heidelberg2014: 303-326Crossref (8) neurosurgery spinal cord injury, maxillofacial surgery, orthopedics joint regeneration pain.7Trivisonno al.Autologous restores soft-tissue contour deformities anomaly: widening horizons employment grafting.Plast Reconstr Surg Glob Open. 2019; 7: e2518Crossref (2) recent phase III randomized trial demonstrated effectiveness allogenic expanded refractory perianal Crohn's disease.8Panés J. García-Olmo Van Assche al.ADMIRE CD Study Group CollaboratorsExpanded allogeneic (Cx601) disease: randomised, double-blind controlled trial.Lancet. 2016; 388: 1281-1290Abstract (463) video begins imaging showing right esophagopleural patient syndrome. identified sutured during toilette pleural cavity, success. Endoscopically, third inferior fully covered (Micro-Tech, Nanjing, China) placed kept place suture Apollo Overstitch (Austin, TX), shown barium swallow study. removed persisted contrast injection. second part shows processing injection submucosa. last role tract has never investigated before report, even if limited, represents first successful literature. Furthermore, process obtaining requires minimal, easily reproducible manipulation necessity any enzymatic digestion expansion. early pushes us further investigate wide potentiality critically ill challenging problems. https://www.gastrojournal.org/cms/asset/2abc5c61-7185-4452-a51b-b00695ea05fa/mmc1.mp4Loading ... .mp4 (52 MB) Help files Supplementary CME Exam 1: Successful Therapy Fistulas Endoscopic Injection Emulsified Adipose Tissue Stromal Vascular FractionGastroenterologyVol. 160Issue 4Preview Full-Text