Fixation of the proximal flange of a lumen-apposing metal stent using a through-the-scope endoscopic suturing system to prevent stent migration in single-session EUS-directed transgastric ERCP: a pilot study.

BACKGROUND AND AIMS: With the global obesity pandemic, clinical scenarios requiring urgent ERCP in patients with gastric bypass surgery are on the rise, and single-session EUS-directed transgastric ERCP (SS-EDGE) can effectively address these technical challenges. The aim of this study was to evaluate and describe the safe and effective use of a through-the-scope endoscopic suturing system for anchoring the lumen-apposing metal stents (LAMSs) during SS-EDGE. METHODS: Six patients with Roux-en-Y gastric bypass (RYGB) underwent SS-EDGE at our center. A through-the-scope endoscopic suturing system was used for anchoring the LAMSs during SS-EDGE. RESULTS: Clinical and technical success was achieved in all 6 patients without any adverse events related to the procedure. No stent migration, pneumoperitoneum, or GI perforation was noted. At the 4-week follow-up, no stent migration was noted, and the through-the-scope suturing system remained anchored. LAMSs along with tacks were removed, and gastric fistulae were successfully closed endoscopically in all patients to prevent weight gain. CONCLUSIONS: Use of through-the-scope endoscopic suturing can be a safe, reliable, and potentially cost-effective novel technique for LAMS fixation to successfully perform SS-EDGE in RYGB patients.

Operative Complications Following Gastrostomy Tube Placement After Cardiac Surgery During Infancy.

INTRODUCTION: Gastrostomy tube (GT) placement is common in infants following repair of congenital heart defects. We aimed to determine rate of operative complications and predictors of short-term GT use to counsel parents regarding the risks and benefits of GT placement. METHODS: We reviewed infants aged <1 y with congenital heart disease who underwent GT placement after cardiac surgery between 2018 and 2021. Demographics and clinical data were collected and analyzed. Comparisons were made between infants who required the GT for more than 1 y and those who required the GT for less than 1 y. RESULTS: One hundred thirty three infants were included; 35 (26%) suffered one or more complication including wound infection (4, 3%), granulation tissue (3, 2%), tube dislodgement (10), leakage from the tube (9), unplanned emergency department visit (15), and unplanned readmission (1). Thirty-four infants used the GT for feeds for 1 y or less (26%) including 17 (13%) who used it for 3 mo or less. Fifty-six infants had their GT removed during the study period (42%), 20 of whom required gastrocutaneous fistula closure (36%). Thirty-three infants had a GT placed on or before day of life 30, 17 (52%) used the GT for less than 1 y, and 10 (31%) used it for 3 mo or less. CONCLUSIONS: GT placement is associated with a relatively high complication and reoperation rate. GT placement in infants aged less than 30 d is associated with shorter duration of use. Risks, benefits, and alternatives such as nasogastric tube feeds should be discussed in the shared decision-making process for selected infants.

Persistent Ostomy Following Percutaneous Endoscopic Gastrostomy Removal: Treatment Strategies.

PURPOSE OF REVIEW: The purpose of this article is to review available literature on management of persistent ostomy following PEG tube removal. We will discuss the incidence of persistent gastrocutaneous fistula (GCF) following PEG tube removal, risk factors for their development, and management strategies that have been proposed and their efficacy. RECENT FINDINGS: The use of over the scope clips (OTSC) have evolved recently in the management of gastrointestinal bleeding, perforation, and fistula closures. OTSC has become more readily available and proven to be effective and safe. Suturing devices have shown promising results. Persistent gastrocutaneous fistula following PEG removal is a rare yet serious complication that can lead to continuous skin irritation and leakage of gastric contents and acid. There are several postulated risk factors but the most important of these is duration of placement. Management can include medical therapy which has recently been shown to be somewhat effective, endoscopic therapy and surgery as a last resort. Overall, the data on GCFs is limited and further study with larger sample size is needed.

Endoscopic closure techniques of bariatric surgery complications: a meta-analysis.

BACKGROUND: Leaks following bariatric surgery, while rare, are potentially fatal due to risk of peritonitis and sepsis. Anastomotic leaks and gastro-gastric fistulae following Roux-En-Y gastric bypass (RYGB) as well as staple line leaks after sleeve gastrectomy have historically been treated multimodally with surgical drainage, aggressive antibiotic therapy, and more recently, endoscopically. Endoscopic clipping using over-the-scope clips and endoscopic suturing are two of the most common approaches used to achieve full thickness closure. METHODS: A systematic literature search was performed in PubMed to identify articles on the use of endoscopic clipping or suturing for the treatment of leaks and fistulae following bariatric surgery. Studies focusing on stents, and those that incorporated multiple closure techniques simultaneously, were excluded. Literature review and meta-analysis were performed with the PRISMA guidelines. RESULTS: Five studies with 61 patients that underwent over-the-scope clip (OTSC) closure were included. The pooled proportion of successful closure across the studies was 81.1% (95% CI 67.3 to 91.7). The successful closure rates were homogeneous (I2 = 39%, p = 0.15). Three studies with 92 patients that underwent endoscopic suturing were included. The weighted pooled proportion of successful closure across the studies was shown to be 22.4% (95% CI 14.6 to 31.3). The successful closure rates were homogeneous (I2 = 0%, p = 0.44). Three of the studies, totaling 34 patients, examining OTSC deployment reported data for reintervention rate. The weighted pooled proportion of reintervention across the studies was 35.0% (95% CI 11.7 to 64.7). We noticed statistically significant heterogeneity (I2 = 68%, p = 0.04). One study, with 20 patients examining endoscopic suturing, reported rate of repeat intervention 60%. CONCLUSION: Observational reports show that patients managed with OTSC were more likely to experience healing of their defect than those managed with endoscopic suturing. Larger controlled studies comparing different closure devices for bariatric leaks should be carried out to better understand the ideal endoscopic approach to these complications.

Endoscopic purse-string suture and naso-jejunal tube feeding for duodenal cutaneous fistula and gastric cutaneous fistula.

BACKGROUND: The Endoscopic Purse-string Suture (EPSS) technique has gained attention for its potential in closing large defects following gastrointestinal procedures. However, its application in fistula closure is not as widely reported. This study aims to evaluate the safety and efficacy of EPSS and naso-jejunal tube feeding in the closure of duodenal cutaneous fistulas and gastric cutaneous fistulas. METHODS: This single-center retrospective study, conducted from September 2020 to September 2023 at Tongji University in Shanghai, China, examined the outcomes of EPPS and nasojejunal feeding for patients with gastric and duodenal cutaneous fistulas (n = 10). Demographic data, fistula characteristics, procedure technique and outcomes were evaluated. RESULTS: In this study, the average size of a fistula opening was 7.9 ± 4.6 mm. The operations took an average of 25.8 ± 5.6 min. Patients typically needed naso-jejunal tube feeding for a median of 14.0 days, with an interquartile range (IQR) of 7.7-19.0 days. The median duration of hospital stay post-operation was 16.5 days, with an IQR of 7.0-25.0 days. Nine patients were successful in their initial fistula closure using the EPSS technique. The other patient underwent a second EPSS and, ultimately, all patients experienced complete healing and fully recovered. There were no major adverse events reported. CONCLUSIONS: EPSS and naso-jejunal tube feeding are a safe and effective treatment option for duodenal and gastric cutaneous fistulas. Larger, prospective studies are needed to validate these findings and establish the long-term safety and efficacy of this approach.

Spontaneous Twin Internal Fistulae: A Rare Complication of Acute Pancreatitis.

Spontaneous internal fistulae (cystocolonic, cystogastric and cystoenteric) have been described as potential complications of severe acute pancreatitis with pseudocyst or walled off necrosis (WON). Ours is possibly the first ever report of double internal fistulae (pancreatico-gastric and pancreatico-colonic) occurring as a spontaneous complication of acute pancreatitis.

Over-the-scope clip for closure of persistent gastrocutaneous fistula after gastrostomy tube removal: a multicenter pediatric experience.

BACKGROUND: Percutaneous endoscopic gastrostomy is commonly used for enteral nutritional access, but gastrocutaneous fistulae (GCF) may persist after tube removal, posing clinical challenges. The use of endoscopic closure devices, including over-the-scope clips (OTSC), has shown promise in managing non-healing fistulae, although data in the pediatric population are limited. METHODS: A retrospective multicenter study analyzed pediatric patients who underwent GCF closure following gastrostomy tube removal. Data from seven centers across multiple countries were collected, including patient demographics, procedural details, complications, and outcomes. Closure techniques were compared between OTSC and surgical closure. RESULTS: Of 67 pediatric patients included, 21 underwent OTSC closure and 46 had surgical closure. Surgical closure demonstrated a higher success rate (100%) compared to OTSC closure (61.9%, P < 0.001). While procedural duration was shorter for OTSC closure (25 vs. 40 min, P = 0.002), complications, and scar quality were comparable between techniques. A subsequent sub-analysis did not reveal differences based on center experience. CONCLUSION: OTSC closure is feasible and safe in pediatric patients, but surgical closure remains superior in achieving sustained GCF closure, although OTSC offers benefits, such as shorter procedural duration, potentially reducing the duration of general anesthesia exposure. Non-operative approaches, including OTSC, may be a valuable alternative to surgical closure.

Effectiveness and safety of a ventricular septal occluder device for the treatment of Gastro-tracheal fistula.

BACKGROUND: Gastro-tracheal fistula (GTF) is one of the most serious complications after esophagogastrostomy and radiotherapy, with very high disability and mortality rates. To evaluate the effectiveness and safety of ventricular septal occluder devices (VSOD) for the treatment of Gastro-tracheal fistula (GTF). METHODS: From January 2020 to May 2022, 14 patients with GTF underwent VSOD under real-time fluoroscopy. The technical success, complications, quality of life (QoL), Eastern Cooperative Oncology Group (ECOG) score, Karnofsky score, and median overall survival (mOS) were recorded and analyzed. RESULTS: Technical success, and major complication rates were 71.4%, and 14.3%, respectively. Both the ECOG and the Karnofsky score showed significant improvement at the 2-month evaluation compared with the pretreatment value (p<0.05). For QoL, general health, physical function, vitality, role physical, and social function all improved at the 2-month evaluation (p<0.05), but bodily pain, role emotion, and mental health showed no significant difference (P>0.05). During the mean follow-up of 9.6 months, eight patients were alive, and the mOS was 11.4 months (95% CI, 8.5-14.3). CONCLUSIONS: VSOD is a simple and safe technique for GTF treatment, but long-term observation is needed at multiple centers to confirm our findings.

Endoscopic management of refractory leak and gastro-cutaneous fistula after laparoscopic sleeve gastrectomy: a randomized controlled trial.

BACKGROUND: Gastro-cutaneous fistula is a rare complication after laparoscopic sleeve gastrectomy (LSG) with incidence of occurrence 1-2%. Most of gastro-cutaneous fistulae do not respond to conservative management and need intervention either surgically or endoscopically. METHODS: This prospective randomized clinical study included referred patients who had LSG performed at our department or other centers, and complicated with post-LSG leak or gastro-cutaneous fistula between December/2019 and March/2021. Included patients were ASA Physical status I-II. Primary and secondary outcomes were recurrence of the fistula and mortality in each group after the intervention during the 18 months follow-up period, respectively. RESULTS: Thirty patients were randomized into two groups: Surgery Group (SG, n = 15) and Endoscopy Group (EG, n = 15). Mean age of patients was 42.3 ± 8.7 and 42.6 ± 8.3 years-old in SG and EG, respectively. Females constituted 73.3% and 80% in SG and EG, respectively. Median time-to-gastric leak post LSG was six (range: 4-7) days in both groups. SG patients were surgically managed with primary repair of the gastric fistula and gastrojejunostomy in 13 patients or converting SG into Roux-en-Y gastric bypass in two patients, while EG patients were endoscopically managed with stitching, stenting, stenting and dilation, and clipping and dilation in 5, 4, 4 and 2 patients, respectively. Incidence of recurrent leak during 1st week was significantly higher in SG than EG (p < 0.001). No mortality reported in EG, while 2 patients died in SG (p = 0.48). CONCLUSION: Endoscopic intervention may offer a successful modality in managing post-LSG gastric leak and gastro-cutaneous fistula that do not respond to conservative measures in stable patients.

Cholecystogastric fistula diagnosed by endoscopic ultrasonography.

A case of a patient with symptoms of gastric obstruction secondary to cholecystogastric fistula is presented and a brief review of the literature is done.

An innovative endoscopic management strategy for postoperative fistula after laparoscopic sleeve gastrectomy.

BACKGROUND: Postoperative fistula is a life-threatening complication that lacks a standard treatment strategy after laparoscopic sleeve gastrectomy (LSG). This observational study is the first to report the efficacy and safety of endoscopic full-thickness resection (EFTR) combined with purse-string sutures in treating this complication. PATIENTS AND METHODS: The old fistula was resected by EFTR, cut radially, and then sutured with a purse-string. The primary endpoint was complete fistula closure within two months. Endoscopic procedure-related complications were also recorded. RESULTS: Eight of 788 LSG patients developed fistulas with an incidence of 1.01%, primarily under the gastroesophageal junction, and the average distance from the center of the fistula to the cardia was 30 ± 6.3 mm. Two patients were cured by conservative treatment, and six received endoscopic sutures. The time from LSG to fistula diagnosis was 12.3 ± 14.4 days. The time from fistula diagnosis to endoscopic repair was 43.8 ± 55.8 days and 21.4 ± 10.0 days after eliminating the data of first case. The average fistula size was 12 ± 10 mm, the average endoscopic procedure duration was 40 ± 16 min, and the average number of endoscopic procedures required was 1.6 ± 0.8. Five patients achieved the primary endpoint, and one patient refused a third endoscopic suture after two sutures. The endoscopy success rate was 83.3%. No endoscopic procedure-related complications occurred. CONCLUSIONS: EFTR combined with purse-string sutures is an innovative, safe, and effective endoscopic strategy for postoperative fistula after LSG, avoiding reoperation and allowing early oral feeding.

A Case Series of Late Gastrointestinal Fistulization in 16 Patients with Walled-Off Necrosis.

BACKGROUND: Gastrointestinal fistulization (GIF) is a rare and potentially fatal complication of acute necrotizing pancreatitis (ANP). There is paucity of data on clinical course and outcome of GIF in walled of necrosis (WON). OBJECTIVE: To evaluate frequency, clinical as well as imaging findings and outcome of spontaneous symptomatic GIF in patients with WON. METHODS: Retrospective analysis of database of patients with asymptomatic WON on regular follow-up over last six years to identify patients with symptomatic GIF. RESULTS: Out of 138 patients with asymptomatic WON seen during the study period, 16 (11.5%) patients (all males; mean age 41.7 ± 9.9 years) developed symptomatic GIF. The mean size of WON in patients who developed GIF was 9.5 ± 2.4 cm, and fistulization occurred after 65.1 ± 17.8 days of the onset of ANP. The site of fistulization was stomach, duodenum, jejunum, colon, and esophagus in seven (43.7%), five (31.2%), one (6.2%), two (12.5%), and one (6.2%) patients, respectively. GIF resulted in spontaneous resolution in two patients (stomach 1 and esophagus 1). The remaining patients with gastric (six patients) and duodenal (five patients) fistulization were successfully treated endoscopically by placing multiple plastic stents in the necrotic cavity after balloon dilatation of the fistulous tract. Patients with colonic fistulization required surgery. None of the patients succumbed to the illness. CONCLUSION: Symptomatic GIF of WON usually occurs within the first three months of onset of ANP. It commonly occurs in either stomach or duodenum and can be successfully managed endoscopically.

Gastrocolic fistula as a rare complication of a benign gastric ulcer.

We report a case of a 77-year-old man presented with abdominal pain, melena and weight loss.He underwent endoscopic evaluation revealed a 1.2cmX0.6cm ulcer of the greater curve of the antrum stomach and a 1.3cm fistulous tract .The gastroscope can smoothly enter the transverse colon through the fistula tract, and we can be able to visualize the colon wall and feces.After the diagnosis of gastrocolic fistula based on endoscopic findings. The patient was referred for surgical evaluation and underwent laparotomy. The patient subsequently underwent en-bloc resection of the fistula, a segment of the transverse colon, gastric perforation repair, intestinal adhesion lysis and peritoneal drainage. Examination of the specimen revealed a fistulous communication between the stomach and resected transverse colon segment. Finally, the patient was discharged 10 days after operation and without further complication.

Gastrocutaneous fistulas after PEG removal in adult cancer patients: frequency and treatment options.

INTRODUCTION AND AIMS: PEG removal in head and neck cancer patients (HNCPs) is performed after treatment, in case of disease remission and after adequate oral intake is resumed. The PEG tract usually closes spontaneously within 2-3 days. Persistent gastrocutaneous fistula (GCF) is a rare complication after PEG tube removal and is characterized by the persistence of gastric leakage through the fistulous tract for more than 1 month. Our main goal was to access the incidence and the success of a treatment algorithm for GCF in HNCPs. METHODS: Retrospective unicentric study of HNCPs referred for PEG removal between 2014 and 2018. The patients with GCF were selected and their sequential treatment was reviewed. RESULTS: In 331 patients with PEGs removed, 19 (5.7%) GCFs were documented. Medical therapy (4-8 weeks) was performed with clinical success (definitive closure of the GCF) in 12 (63.2%) patients. The remaining seven patients required endoscopic or surgical treatment. In four, endoscopic treatment had technical and clinical success (in three patients with fulguration of the gastric leak edges with argon plasma coagulation, silver nitrate in the path and external orifice, and closure of the internal orifice with hemoclips and in one with an over-the-scope-clip). Only three patients underwent surgery, one due to clinical failure of sequential endoscopic therapy and two had direct surgery. CONCLUSION: GCF occurs rarely after PEG removal in HNCPs. Medical therapy is usually effective and should be maintained for at least 8 weeks. Endoscopic therapy is an effective second-line option with and surgery rarely required.

Gastropericardial fistula in a patient with upside-down stomach and stomach perforation: a case report.

BACKGROUND: Gastropericardial fistula is a pathological communication between the stomach and the pericardium. This case report describes a gastropericardial fistula in a patient with upside-down stomach. CASE PRESENTATION: The male patient (86) was examined for severe chest pain behind the sternum. CT revealed upside-down stomach with perforation on the lesser gastric curvature and fistulation into the pericardium with pneumopericardium. The patient was indicated for surgery. The procedure was performed from a transverse laparotomy and consisted of repositioning the stomach into the abdominal cavity, resection of the hernial sac, suture of the perforation of the lesser curvature, gastropexy and transhiatal drainage of the mediastinum and lesser sac. In the early postoperative period, the recovery was uneventful. Acute myocardial infarction with cardiorespiratory failure developed on the postoperative day (POD) 13. The patient died on POD 24 due to cardiorespiratory failure, confirmed by a sectional finding. CONCLUSIONS: Gastropericardial fistula is a rare acute complication of the diseases of the upper GIT. It is invariably a serious, life-threatening condition. Diagnosis is confirmed by thoracic CT and a contrast swallow study. The necessity of acute surgical treatment is widely accepted. The type of procedure must be selected based on the patient's individual criteria.

[Gastric bezoars caused by enteral nutrient gel via gastric fistula in a patient with esophageal cancer].

A 62-year-old man presented to our hospital with difficulty in swallowing. Physical examination and subsequent diagnostic tests identified hypopharyngeal and esophageal carcinoma with tracheal invasion. The patient underwent gastric fistula placement, radiotherapy, and chemotherapy. Palliative care was initiated after recurrence. The patient was later hospitalized for neck pain, and during a routine exchange of the gastric fistula, two large bezoars were found. The enteral nutrient gel was discontinued, cola was administered, and the bezoars gradually reduced. He continued to receive home care, and later when he was hospitalized for mediastinal abscess, no bezoars were identified. This case highlights the possibility of bezoar formation as a rare complication of enteral nutrition gel administration.

Percutaneous embolization for a subacute gastric fistula following laparoscopic sleeve gastrectomy: a case report and literature review.

BACKGROUND: The management for subacute or chronic fistula after bariatric surgery is very complicated and with no standard protocol yet. It is also an Achilles' heel of all bariatric surgery. The aim of this case report is to describe our experience in managing this complication by percutaneous embolization, a less commonly used method. CASE PRESENTATION: A 23-year-old woman with a body mass index of 35.7 kg/m2 presented with delayed gastric leak 7 days after laparoscopic sleeve gastrectomy (LSG) for weight reduction. Persistent leak was still noted under the status of nil per os, nasogastric decompression, and parenteral nutrition for 1 month; therefore, endoscopic glue injection was performed. The fistula tract did not seal off, and the size of pseudocavity enlarged after gas inflation during endoscopic intervention. Subsequently, we successfully managed this subacute gastric fistula via percutaneous fistula tract embolization (PFTE) with removal of the external drain 2 months after LSG. CONCLUSIONS: PFTE can serve as one of the non-invasive methods to treat subacute gastric fistula after LSG. The usage of fluoroscopy-visible glue for embolization can seal the fistula tract precisely and avoid the negative impact from gas inflation during endoscopic intervention.

Creativity in Containing a Patient's High-Output Fistula: A Case Report.

A gastrogastric fistula is a rare complication of Roux-en-Y gastric bypass resulting from communication between the gastric pouch and gastric remnant. This case report describes the creative interprofessional management of this condition arising in a 48-year-old woman. During an elective Roux-en-Y gastric bypass surgery for morbid obesity, the patient developed respiratory complications. She was admitted to the ICU, but the following day she signed herself out against medical advice, stating she was "no longer staying here." Within 24 hours, she returned to the ED for postoperative complications, and a week after the exploratory surgery, the patient developed an inoperable high-output fistula. The authors devised a creative solution to contain the effluent and achieved closure of the fistula after several weeks.

Management of gastrocutaneous fistulas following gastrostomy: surgery as a therapeutic option.

Gastrocutaneous fistulas (GCF) following removal of gastrostomy tubes are an uncommon complication with many therapeutic options. It is a drawback that concerns both patient and surgeon, hindering the decision to perform an invasive treatment. Despite emerging minimally invasive procedures, we must not forget that surgery continues to be the standard treatment when they all fail.