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Endoscopic closure of gastrocolic fistula using clips and detachable ligatures

      A 49-year-old man presented with a history of Billroth II for peptic ulcer disease about 20 years ago. He developed multiple small-bowel obstructions over the years and had 3 exploratory laparotomies including small-bowel resection and the formation of a Braun anastomosis. He eventually had a definitive revisional surgery with conversion to a Roux-en-Y bypass anatomy about 5 years earlier. He presented to our hospital with postprandial abdominal pain, diarrhea, and severe malnutrition. On presentation he was cachectic with a BMI of 14 and severe electrolyte disturbance. He underwent an EGD to evaluate for a possible marginal ulcer; a gastrocolic fistula at the level of the gastrojejunal anastomosis was identified unexpectedly. The cecum was identified endoscopically to confirm the presence of a gastrocolic fistula. Given the extensive past surgical history and severe malnutrition, we chose to endoscopically attempt closure of the fistula to avoid or delay any major revisional surgery (Video 1, available online at www.VideoGIE.org).
      The gastrocolic fistula was about 6 mm × 16 mm and had refluxed colonic fecal material. Initially, the placement of 3 sets of endoscopic sutures in the gastric pouch was unable to show closure with imaging. The patient continued to clinically pass solid food directly from the gastric pouch into the large bowel (Fig. 1). A 30F gastroscope (GIB-1TH190; Olympus America, Southborough, Mass, USA) and a 39.6F adult colonoscope (CF-HQ190L; Olympus America) were used simultaneously to visualize the fistula from the upper and lower intestinal tract (Fig. 2). Fluoroscopy was used to help further visualize the positions of the endoscopes. The gastric pouch was visualized, and the gastroscope traversed the gastrocolic fistula into the colon.
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      Figure 1Upper-GI series with small-bowel follow-through showing gastric (left) and colic (right) fistula.
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      Figure 2Endoscopic visualization with adult colonoscope on the colonic side of the large fistulous track, showing width of the fistula compared with the colonoscope.
      Having located tissue that was more viable than elsewhere, we chose to attempt closure on the colonic side of the fistula using hemostatic clips. After placement of 7 clips using the zipper technique, there remained persistent communication with the gastric lumen. We placed 2 detachable ligatures to further close the defect but were unsuccessful. Using the same technique on the gastric side, we placed clips, followed by 3 detachable ligatures, to close the defect (Fig. 3). Closure was suggested by a lack of refluxed water to either side of the fistula. After endoscopy, an upper-GI series with small-bowel follow-through did not show persistence of the gastrocolic fistula (Fig. 4). For the next 4 weeks, the patient was able to completely digest his food, suggesting no food passing the fistulous tract prior to symptoms recurring, necessitating surgery. It is well known that these fistulas always open again, but endoscopic closure provided additional time for our patient to be further medically optimized before any surgical intervention.
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      Figure 3Endoscopic appearance of the gastric side of the fistula after closure with hemoclips and endoloop.
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      Figure 4Upper-GI series with small-bowel follow-through showing absence of the gastrocolic fistula and lack of contrast material traversing the fistula into the colon because of clips placed (far right).
      Our case demonstrates an endoscopic technique to safely close a wide, chronic, gastrocolic fistula using clips and detachable ligature in a patient who was a high-risk surgical candidate.

      Disclosure

      All authors disclosed no financial relationships relevant to this publication.

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