Use of an over-the-scope clip for endoscopic sealing of a gastric fistula after sleeve gastrectomy

Perforation or development of a fistula in the gastrointestinal tract is a serious complication. A gastrocutaneous fistula after sleeve gastrectomy is difficult to treat, with a mortality rate of 85 % following unsuccessful treatment [1]. These fistulas have been successfully managed with endoscopic fibrin sealing [2]. Preliminary experience with the over-the-scope clipping system (Ovesco, Tubingen, Germany) has shown the efficacy of this intervention in the management of severe bleeding and perforations of the gastrointestinal tract [3] [4] [5].

This is the first report of the use of an over-the-scope clipping for the management of a gastric fistula. A 43-year-old woman underwent sleeve gastrectomy for morbid obesity. After 1 week, a fistula developed at the proximal end of the suture, 2 cm distal to the esophagogastric junction. A nasogastric drain and an ultrasound-guided external drain were inserted. Endoscopy showed a 7-mm orifice ([Fig. 1]). [Fig. 2] shows the extravasion of contrast medium, confirming the presence of a fistula. Two attempts to seal the fistula with hemoclips failed.

Fig. 1 Endoscopic fistula.

Fig. 2 X-ray examination showing the extravasion of contrast medium.

Placement of a large, colorectal expandable covered stent (Taewoong, Korea) was also attempted. The patient could not eat and complained of severe epigastric pain. The stent was removed 3 weeks later. Surgery was carried out, but the fistula reappeared 1 week later and a gastrocutaneous fistula was diagnosed.

The over-the-scope clipping system was used to overcome the limitations presented by the available hemoclips. The over-the-scope clip is delivered by means of an applicator cap placed on the tip of the endoscope. A catheter with a retractable anchor was introduced through the fistula and the grasped tissue firmly pulled inside the cap ([Fig. 3] and [4]).

Fig. 3 The over-the-scope clipping system with the anchor catheter.

Fig. 4 The anchor catheter introduced through the fistula.

The clip was then released and the fistula successfully closed. The patient was allowed to eat her usual diet 24 hours later after post-treatment evaluation. She was then discharged. The endoscopic and radiologic controls performed after 1 and 2 weeks confirmed sealing of the fistula ([Fig. 5]).

Fig. 5 Fluoroscopic control after treatment with the over-the-scope clipping system.

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References

• 1 Rolandelli R, Roslyn J J. Surgical management and treatment of sepsis associated with gastrointestinal fistulas.  Surg Clin North Am. 1996;  76 1111-1122
• 2 Papavramidis T S, Kotzampassi K, Kotidis E. et al . Endoscopic fibrin sealing of gastrocutaneous fistulas after sleeve gastrectomy and biliopancreatic diversion with duodenal switch.  J Gastroenterol Hepatol. 2008;  23 1802-1805
• 3 Kratt T, Küper M, Traub F. et al . Feasibility study for secure closure of natural orifice transluminal endoscopic surgery gastrotomies by using over-the-scope clips.  Gastrointest Endosc. 2008;  68 993-996
• 4 Kirschniak A, Kratt T, Stüker D. et al . A new endoscopic over-the-scope clip system for treatment of lesions and bleeding in the GI tract: first clinical experiences.  Gastrointest Endosc. 2007;  66 162-167
• 5 Kirschniak A, Traub F, Kueper M A. et al . Endoscopic treatment of gastric perforation caused by acute necrotizing pancreatitis using over-the-scope clips: a case report.  Endoscopy. 2007;  39 1100-1102