Brian S. Lim, MD, MCR from Kaiser Permanente Riverside Medical Center at the University of California Riverside School of Medicine presents this video case titled “Over-the-scope clip for closure of persistent post-esophagectomy gastric conduit fistula.”
A 69-year-old man had an Ivor-Lewis esophagectomy for esophageal carcinoma. On postoperative day 6, the patient developed severe chest pain; CT revealed a defect at the anastomosis. EGD showed a large opening at the anastomosis, and a fully covered metal stent was placed. CT 10 days after EGD was positive for a persistent defect. Given the impression of proximal stent migration during the second EGD, an additional stent was placed overlapping the existing stent. With a repeat esophagram showing continued leakage, another EGD was performed. A detailed examination of the region of interest after stent extraction demonstrated that the active opening was 3 to 4 cm distal to the original anastomotic leak, suspicious for a gastric conduit fistula. Hemoclips were deployed on both edges then pulled together with endoloops. The patient was discharged home but had worsening symptoms days later. Subsequent EGD showed a persistent fistula for which over-the-scope clips (OTSC) were used, resulting in complete healing.
In recent years, endoscopic devices such as clips and stents have been used for closure of postoperative defects of the GI tract. More recently, OTSC have been used. We wanted to use this video forum to demonstrate that OTSCs can facilitate successful closure of postoperative defects/fistulas that are difficult to manage with other known endoscopic methods.
Attachment of OTSC to the endoscope and its application mechanism are similar to those of the band ligation device; knowledge and skill behind performing band ligation for varices should help in learning how to use OTSC.
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