Management of fistulas in the upper gastrointestinal tract.

Fistulas in the upper gastrointestinal (GI) tract are complex conditions associated with elevated morbidity and mortality. They may arise as a result of inflammatory or malignant processes or following medical procedures, including endoscopic and surgical interventions. The management of upper GI is often challenging and requires a multidisciplinary approach. Accurate diagnosis, including endoscopic and radiological evaluations, is crucial to build a proper and personalized therapeutic plan, that should take into account patient's clinical conditions, time of onset, size, and anatomical characteristics of the defect. In recent years, several endoscopic techniques have been introduced for the minimally invasive management of upper GI fistulas, including through-the-scope and over-the-scope clips, stents, endoscopic suturing, endoluminal vacuum therapy (EVT), tissue adhesives, endoscopic internal drainage. This review aims to discuss and detail the current available endoscopic techniques for the treatment of upper GI fistulas.

Gastropericardial fistula: A successfully operated heart code.

Gastropericardial fistula is a rare, extremely serious and life-threatening condition. Its most common aetiology is secondary to iatrogenic injury following gastric surgery. Clinical manifestations may be non-specific with precordial pain, simulating an acute coronary syndrome, and may be accompanied by electrocardiogram abnormalities. Diagnosis is made by thoracoabdominal computed tomography (CT) with oral and intravenous contrast. Treatment is surgical and consists of repair of the anomalous communication. We present the case of an 81-year-old male patient with gastropericardial fistula who underwent surgery, with the aim of reviewing the diagnosis and the appropriate therapeutic strategy.

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.

Gastrosplenic Fistula Secondary to Simultaneous Gastric and Splenic Diffuse Large B-Cell Lymphoma.

Gastrosplenic fistula is a rare complication arising mainly secondary to involvement of the stomach or spleen by lymphoma. A delayed diagnosis is associated with high morbidity and mortality. We present a case of gastrosplenic fistula secondary to gastric and splenic involvement by diffuse large B-cell lymphoma with relevant imaging findings. The patient was successfully treated with surgical resection.

Tratamiento endoscópico de una fístula aguda tras gastrectomía vertical laparoscópica / Endoscopic treatment of an acute fistula after laparoscopic sleeve gastrectomy / Tratamento endoscópico de uma fístula aguda após gastrectomia vertical laparoscópica

La fístula gástrica aguda es una de las principales complicaciones vinculadas a la gastrectomía vertical laparoscópica (GVL). Existen múltiples opciones terapéuticas para su resolución, siendo el tratamiento endoscópico mediante colocación de clips o stents uno de los más importantes. La aplicabilidad de cada método va a depender del tipo de fístula y del estado del paciente. Presentamos el caso de una mujer de 35 años, que desarrolla una fístula aguda posterior a una GVL. Se realiza tratamiento endoscópico con colocaciónn del sistema "over-the-scope clip" (Ovesco®) a nivel del orificio fistuloso, con posterior colocaciónn de stent metálico auto expandible.

Acute gastric fistula is one of the main complications associated with laparoscopic vertical gastrectomy (LVG). There are multiple therapeutic options for its resolution, being endoscopic treatment by placing clips or stents one of the most important. The applicability of each method will depend on the type of fistula and the patient's condition. We present the case of a 35-year-old woman who developed an acute fistula after LGV. Endoscopic treatment is performed with placement of the over-the-scope clip system (Ovesco®) at the level of the fistulous orifice, with subsequent placement of a self-expanding metal stent.

A fístula gástrica aguda é uma das principais complicações associadas à gastrectomia vertical laparoscópica (GVL). Existem múltiplas opções terapêuticas para a sua resolução, sendo o tratamento endoscópico com colocação de clipes ou stents uma das mais importantes. A aplicabilidade de cada método dependerá do tipo de fístula e do estado do paciente. Apresentamos o caso de uma mulher de 35 anos que apresentou uma fístula aguda após GVL. O tratamento endoscópico foi realizado com a colocação do sistema de clipe over-the-scope (Ovesco®) no nível do orifício fistuloso, com posterior colocação de stent metálico autoexpansível.

Malignant hepatogastric fistula with associated secondary liver abscess: a rare complication of an occult gastric adenocarcinoma.

A 73-year-old woman presented with fever and right flank pain. The admission was complicated by sepsis, myocardial ischaemia and an upper gastrointestinal bleed. A gastroscopy eventually demonstrated a large antral adenocarcinoma. Further imaging showed no evidence of metastasis, but demonstrated a large segment 3 hepatic abscess. At laparotomy, a hepatogastric fistula (HGF) was noted and a synchronous subtotal gastrectomy and left lateral liver sectionectomy was performed. Final histology showed complete resection of the gastric cancer (T4bN2) and confirmed the presence of the fistula. The patient was discharged 10 days later. She passed away 6 months later with local recurrence, hepatic and pulmonary metastasis. We include a review summarising the other causes of HGF in the literature.

Case report of a 72-year-old man with diaphragmatic hernia and thoracic gastropericardial fistula after esophagectomy for 18 years.

BACKGROUND: Both diaphragmatic hernia and thoracic gastropericardial fistula rarely occur simultaneously in patients with radical esophagectomy. CASE PRESENTATION: A 72-year-old man presented to our hospital with 1 day of nausea, vomiting and acute left chest pain. He had radical esophagectomy (Sweet approach) for esophageal cancer 18 years ago. Computed tomography (CT) of the chest revealed diaphragmatic hernias and air collection within the pericardial space. While an operation of diaphragmatic hernia repair was decisively performed to prevent further serious complications, unusually, a thoracic gastropericardial fistula was also found unusually. CONCLUSION: Diaphragmatic hernia and thoracic gastropericardial fistula may occasionally coexist in patients with esophagectomy. Upper GI radiograph with a water-soluble contrast agent is a better diagnostic tool than CT in visualizing the fistula.

Early gastrogastric fistula after Roux-en-Y gastric bypass: successful fistula treatment with self-expandable endoscopic stent.

A 25-year-old patient underwent laparoscopic Roux-en-Y gastric bypass surgery with an initially uneventful postoperative course. Two weeks postoperatively, the patient presented with acute abdominal pain. CT scan revealed a gastrogastric fistula from the gastric pouch to the gastric remnant. Laparoscopic drainage was performed, and intraoperative endoscopy confirmed a large gastrogastric fistula. Due to intense adhesions between pouch and remnant, a closure by suture of the fistula was not possible. The fistula was initially treated with a fully covered metal stent. After multiple stent migrations despite clip attachment to the mucosa, the stent was changed to a partially covered metal stent. Fistula healing progress was documented every 2 weeks. After 10 weeks of stent treatment, fistula closure was accomplished.In conclusion, early fistula from the gastric pouch to the gastric remnant is a rare complication and can be managed with endoscopic stent placement.

A gastro-colic fistula secondary to high-grade B-cell gastric lymphoma in a patient with AIDS: a case report.

To the best of our knowledge, there are no previous reports of a gastro-colic fistula (GCF) secondary to primary high-grade B-cell gastric lymphoma associated with acquired immunodeficiency syndrome (AIDS). Here, we report a 37-year-old man who presented with paroxysmal abdominal pain for 4 months, diarrhea for 15 days and weight loss of 4 kg. He had a history of human immunodeficiency virus (HIV) infection and was diagnosed with AIDS in 2013. The patient was diagnosed with a GCF secondary to primary high-grade B-cell gastric lymphoma by gastroscopy and histopathological examination. Two weeks after diagnosis, he died in another hospital. This is an uncommon case in which the GCF occurred secondary to malignant gastric lymphoma in a patient with AIDS. Supported by the literature, patients with HIV infection who complain of abdominal pain or a mass, severe diarrhea, and weight loss should be assessed for a GCF secondary to lymphoma because of its worse prognosis.

Test Characteristics of Abdominal Computed Tomography for the Diagnosis of Gastro-gastric Fistula in Patients with Roux-en-Y Gastric Bypass.

INTRODUCTION: Gastrogastric fistulae (GGF) occur in 1-6% of Roux-en-Y gastric bypass (RYGB) patients. Many patients undergo abdominal computed tomography (CT) as an initial test owing to its wide availability; however, CT diagnostic accuracy for GGF is unclear. Our aim was to evaluate test characteristics of abdominal CT compared to upper gastrointestinal series (UGI) and esophagogastroduodenoscopy (EGD) for diagnosing GGF using surgery as a gold standard. METHODS: Retrospective review of RYGB patients who underwent abdominal CT with oral contrast within 1 year. Demographics, weight parameters, and symptoms were collected. Surgery within 1 year of the diagnostic tests was included as the gold standard comparison. Primary outcomes included CT sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy (DA) for GGF. RESULTS: One hundred thirty-seven patients were included, where 42 (30.1%) had positive CT and 95 (69.3%) had negative CT for GGF. Compared to surgical confirmation, CT abdomen with PO contrast had sensitivity of 73.1% (59-84.4), specificity of 95.2% (88.3-98.7), PPV 90.5% (77.4-97.3), NPV of 85.1% (76.3-91.2), and DA 89.7%. UGI series had sensitivity of 58.5% (42.1-73.7), specificity of 98.8% (93.5-99.9), PPV of 96% (79.7-99.9), NPV of 82.8% (73.9-89.7), and diagnostic accuracy (DA) of 85.4%. EGD had sensitivity of 78.3% (63.6-89.1), specificity of 98.8% (93.5-99.9), PPV 97.3 (85.8-99.9), and DA 91.5%. There were no significant differences in diagnostic test characteristics among modalities. CONCLUSIONS: Abdominal CT with oral contrast has similar diagnostic test characteristics to UGI and EGD at detecting GGF when using surgical diagnosis as a gold standard.

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 Fistula in the Chest After Sleeve Gastrectomy: a Systematic Review of Diagnostic and Treatment Options.

This study aimed to establish the optimal diagnostic and treatment algorithm for the management of gastric fistula in the chest (GFIC) after sleeve gastrectomy (SG) through a systematic review of published cases. A multi-database search was performed, which produced 1182 results, of which 26 studies were included in this systematic review. The initial presentation included subphrenic collections, leaks, or (recurrent) pneumonia with associated symptoms such as persistent cough, fever, and/or dyspnea. Computed tomography (CT) scan in combination with either upper gastrointestinal (UGI) series or an esophagogastroduodenoscopy (EGD) was used to adequately diagnose the fistulas. Initial treatment was either with clips and/or clips and stents that were placed endoscopically. When unsuccessful in the majority of the cases, the surgical treatment consisted of total gastrectomy and Roux-en-Y esophagojejunostomy in a laparoscopic or open fashion.