Fistula closure using a ventricular septal occluder

Dr KumbhariVivek Kumbhari, MD from the Department of Medicine and Division of Gastroenterology and Hepatology at The Johns Hopkins Medical Institutions in Baltimore, Maryland, USA shares this video case “Closure of a large, persistent enterocutaneous fistula by use of a ventricular septal occluder.”

We demonstrate the use of a ventricular septal occluder (Amplatzer; St Jude Medical, Plymouth, Minn) to close a large jejunocutaneous fistula. This device is a self-expandable double umbrella–shaped polyester-covered nitinol wire mesh. An 80-year-old woman was seen for management of a chronic, iatrogenic jejunocutaneous fistula that resulted from a percutaneous jejunal feeding tube removed 7 years ago. Conscious sedation was used, and the patient was discharged home the same day. The patient recommenced her diet, and no leakage through the fistula was observed at follow-up.

We demonstrate the technical feasibility and efficacy of the ventricular septal occluder for the short-term closure of a large enterocutaneous fistula. Enterocutaneous fistulas are associated with a significant morbidity and a mortality. The most common causes are iatrogenic (jejunal feeding), Crohn’s disease, radiotherapy-induced, and secondary to malignancy. These patients are often poor surgical candidates, and hence a minimally invasive management strategy may offer significant benefits.

This novel technique may be an alternative closure method in cases in which standard endoscopic methods do not provide resolution.  There are two types of cardiac septal occluder (atrial and ventricular) and the fistula should be carefully assessed to allow the selection of the appropriate one. Primary closure of the fistula with investigation and management of downstream stenosis should be performed prior to the use of the septal occluder.

Although technically simple and efficient, we do not recommend this technique as a long-term durable method of fistula closure. It should be used with the intention of providing relief of symptoms and/or optimization of nutritional status so that the patient can more safely undergo definitive intervention. This device, unless secured, will migrate in due course and one may consider fixing the device to the skin with sutures.

Find more VideoGIEs available online.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.

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