Brian P. Riff, MD from the Division of Gastroenterology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania in Philadelphia, Pennsylvania, USA describes this VideoGIE case, “A novel technique for over-the-scope clip application: a safer and more secure method.”
The video case demonstrates our preferred technique for closing persistent gastrocutaneous fistulas (GCF). The patient is a 91-year-old male that had a gastrostomy tube removed 3 months prior with continued high volume drainage. In addition to showing a technique for closing a GCF, the video shows a safe method to help localize the enterocutaneous fistula defect while at the same time increasing mucosal purchase for over-the scope-clip (OTSC) application.
We felt that this case was important because it demonstrates proper technique for OTSC application in the stomach. In addition, we feel this technique is the most effective way to close a persistent GCF following gastrostomy tube removal. Multiple other endoscopic techniques have been described with disappointing results including through the scope clips, banding, and tissue glue. In our method, the guidewire helps to localize the exact defect; occasionally during closure one can become disoriented or obscure the GCF during OTSC application. The guidewire will not become stuck in the OTSC after firing so that is something that endoscopists need not worry about. In addition, by providing external pressure at the defect, the OTSC can get much greater mucosal purchase without the need for auxiliary devices. The increased mucosal adherence will help prevent clip migration which has been the major technical issue related to OTSC use in the stomach.
Figure 1. Over-the-scope 12/6t closure of a gastrocutaneous fistula by using ERCP guidewire placement and external pressure to increase mucosal purchase.
Persistent GCF following gastrostomy tube removal is more common than physicians recognize in the adult population with a range of 2-44% in series. This wide variance is because most gastrostomy tube series are in terminal indications and are not removed. In much larger series in the pediatric literature, persistent GCF is seen in 24% of patients following gastrostomy removal. Adult gastroenterology should be aware of this adverse event related to one of our procedures and know that they can be successful closed in one endoscopic session using an OTSC. We hope that our technique will be adopted in order to increase the safety of the procedure and limit the chances of clip migration or misplaced deployment.
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