Wire-guided over-the-scope clip method for closing gastrobronchial fistula

Gastric fistula is a significant complication that develops in 0.9 % – 2.6 % of cases after bariatric surgery [1]. Although gastrobronchial fistula (GBF) is a rare gastric fistula, it can generally be treated with thoracotomy and laparotomy but with high mortality rates.

A 52-year-old man who had undergone a mini-gastric bypass operation (preoperative body mass index 38 kg/m²) 4 months earlier was admitted to our hospital with GBF and secondary complications. Endoscopic evaluation revealed a fibrotic fistula orifice, approximately 7 – 8 mm in diameter, in the proximal fundus ([Fig. 1]). A balloon catheter loaded with a guidewire was inserted into the fistula tract. Fistulography showed leakage of contrast medium into the left subdiaphragmatic area and left bronchus ([Fig. 2]). After checking the cavity with the balloon, the wire was left in the fistula tract and the endoscope was removed ([Video 1]). The endoscope was loaded with a 12-mm over-the-scope clip (OTSC) and reinserted into the fistula tract over the wire. The OTSC was deployed and the fistula orifice was closed, with the wire in the center of the clip. The wire was removed easily from the middle of the clip. Fluoroscopy confirmed no contrast leakage into the fistula tract, and endoscopy showed the fistula orifice to be totally closed ([Fig. 3]). The patient was completely well during the first year of follow-up.

Fig. 1 Endoscopic view of fibrotic fistula orifice in the proximal fundus.

Fig. 2 Fistulography showed leakage of contrast medium into the subdiaphragmatic area (arrow) and the left bronchus (arrowhead).

Video 1 The wire-guided technique for closure by over-the-scope clip.

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Fig. 3 On endoscopy, the fistula orifice appeared to be completely closed.

Unlike classical closure methods, the OTSC method used in this case involved wire guidance, with the wire still in place when the fistula orifice was closed. This wire-guided OTSC method, which has been reported previously [2], was preferred to the use of the OTSC Anchor and Twin Grasper (Ovesco, Tübingen, Germany) because it reduces the mobility of the OTSC through close proximity to the lumen wall, and suction can be performed without damage to fibrotic tissue.

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• References

• 1 Abou Rached A, Basile M, El Masri H. Gastric leaks post sleeve gastrectomy: review of its prevention and management. World J Gastroenterol 2014; 20: 13904-13910
• 2 Tabibian JH, Kochman ML. Over-the-wire technique to facilitate over-the-scope clip closure of fistulae. Gastrointest Endosc 2017; 85: 454-455