Closure of refractory gastrocutaneous fistula using submucosal dissection and over-the-scope clip assisted by a standard clip

Percutaneous endoscopic gastrostomy is performed to gain enteral nutritional access in patients with impaired swallowing. However, gastrocutaneous fistula (GCF) may persist in up to 25% of cases following tube removal [11]. Endoscopic submucosal dissection (ESD) to re-epithelialize the fistulous tract, combined with closure using an over-the-scope (OTS) clip, has been reported as a safe and effective approach for managing persistent GCF [22] [33] [44]. A twin grasper is commonly used to pull the GCF into the OTS clip before the clip is deployed. A recently introduced, mantis-like claw clip – Mantis clip (Boston Scientific, Marlborough, Massachusetts, USA) – has demonstrated excellent efficacy in closing large gastrointestinal defects [55]. This reopenable, rotatable, through-the-scope clip features anchor prongs designed to securely grasp wound edges. Here, we describe a case in which we combined ESD of the GCF with closure using an OTS clip assisted by the Mantis clip, eliminating the need for a twin grasper and reducing costs.

We report the case of a 77-year-old patient with refractory GCF persisting 24 weeks after gastrostomy removal. A circumferential ESD was performed to ablate the fistulous tract and promote healing. Closure was achieved using an OTS clip (Ovesco, Olympus, Tokyo, Japan) assisted by a Mantis clip. Each edge of the fistula was sequentially grasped using the Mantis clip with a “hold-and-drag” strategy, preventing slippage. The OTS clip was then deployed, and contrast opacification confirmed the absence of leakage ([Video 1Video 1]). The patient was discharged on post-procedure day 1 without complications and showed no recurrence at the 1-month follow-up.

Endoscopic submucosal dissection and closure of a gastrocutaneous fistula using a Mantis clip and an over-the-scope clip following percutaneous gastrostomy tube removal in a 77-year-old patient.Video 1Video 1

The design of the Mantis clip, featuring grasping teeth, provides excellent tissue grip and can serve as an alternative to the twin grasper when placing an OTS clip. Its greater availability and significantly lower cost compared to the twin grasper make this strategy particularly appealing.

Endoscopy_UCTN_Code_TTT_1AO_2AK

Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Hucl T, Spicak J. Complications of percutaneous endoscopic gastrostomy. Best Pract Res Clin Gastroenterol 2016; 30: 769-781
• 2 Lafeuille P, Wallenhorst T, Lupu A. et al. Endoscopic submucosal dissection combined with clip for closure of gastrointestinal fistulas including those refractory to previous therapy. Endoscopy 2022; 54: 700-705
• 3 Teitelbaum JE, Gorcey SA, Fox VL. Combined endoscopic cautery and clip closure of chronic gastrocutaneous fistulas. Gastrointest Endosc 2005; 62: 432-435
• 4 Gay-Chevallier S, Lupu A, Rivory J. et al. Closure of non-healing gastrocutaneous fistula after percutaneous endoscopic gastrostomy by endoscopic submucosal dissection and over-the-scope clip. Endoscopy 2019; 51: E125-E126
• 5 Nishiyama N, Matsui T, Nakatani K. et al. Novel strategy of hold-and-drag clip closure with mantis-like claw for post-gastric endoscopic submucosal dissection defect of < 30 mm. Endoscopy 2023; 55: E1244-E1245

Publikationsverlauf

Artikel online veröffentlicht:
03. März 2025