A0450 - A Novel Procedure for Recurrent Gastrocutaneous Fistulas: Enhancing the Over the Scope Clip

Kevin Mai, BS¹, Kuang Cheng Chen, BS¹, Sadie De Silva, MD², Shehan Thangaratnam, BS³, Sanskriti Sharma, MD⁴, Zi Qian Liu, BS⁵, Paarth Kansal, BS⁶, Kumaravel Perumalsamy, MD⁷, Duminda Suraweera, MD⁷, Vivaik Tyagi, MD^7
1Western University of Health Sciences, Pomona, CA; ²UHS SoCal MEC, Temecula, CA; ³California University of Science and Medicine, Colton, CA; ⁴WellStar Atlanta Medical Center, Atlanta, GA; ⁵Midwestern University, Glendale, AZ; ⁶California Northstate University, Elk Grove, CA; ⁷Gastro Care Institute, Lancaster, CA

Introduction: Gastrocutaneous fistulas (GCF) commonly arise from iatrogenic injury. Although they tend to self-resolve with conservative treatments, many fistulas recur or persist (1). Standardized treatments for these patients include surgical closure, fibrin glue, or endo-clipping (2, 3). However, the recurrence of GCFs following repair occurs in an estimated 20% of cases (4, 5). While the applications of over the scope clip show promising results, its use is limited by the luminal size of the fistula. Therefore, we present an innovative technique utilizing submucosal injections of histoacryl glue to successfully facilitate and stabilize over the scope clips. Overall, successfully closing recurrent GCFs with enlarged lumens.

Case Description/Methods: A female in her 40’s presents with abdominal pain and recurrence of GCFs. She holds a history of a hiatal hernia, Nissen fundoplication, treatment for a perforated viscus and gastrostomy tube placement. Standardized treatments of the fistula included surgical excision and conservative management with proton pump inhibitors, octreotide, and total parenteral nutrition. Since the fistulas were refractory to standardized treatments, a novel technique was used. A gastroduodenoscope helped visualize the gastric fundal region where a >10mm fistula was located. A histoacryl glue solution (1mL saline and 0.5mL histoacryl) was then injected into the submucosal space surrounding the fistula, approximating the luminal surface. A pad lock, over the scope clip was then advanced to the site where suction helped further approximate the tissue. Application of the clip cleared any notable air leaks demonstrating adequate closure of the fistula. The same technique was utilized for the second >10mm fistula in the gastric antrum with adequate closure.

Discussion: Reviews have demonstrated that most successful treatments of fistulas with over the scope clips occur in cases where the lumen is < 10mm (6, 7). The successful treatment of two fistulas measuring >10mm with histoacryl glue prior to over the scope clip application demonstrates the reliability of this innovative technique and may reinvent current standards. The success with this technique may be attributed to a few elements of histoacryl glue. Firstly, compared to fibrin glue, histoacryl is not a protein and therefore resists enzymatic degradation from gastric secretions and fistula effluent.


Disclosures:


Kevin Mai, BS¹, Kuang Cheng Chen, BS¹, Sadie De Silva, MD², Shehan Thangaratnam, BS³, Sanskriti Sharma, MD⁴, Zi Qian Liu, BS⁵, Paarth Kansal, BS⁶, Kumaravel Perumalsamy, MD⁷, Duminda Suraweera, MD⁷, Vivaik Tyagi, MD⁷. A0450 - A Novel Procedure for Recurrent Gastrocutaneous Fistulas: Enhancing the Over the Scope Clip, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.