Post written by Tarun Kaura, MD, from the Aurora St Luke’s Medical Center, Milwaukee, Wisconsin, USA.
A 60-year-old female presented with acute pancreatitis complicated by large acute pancreatic fluid collection, which later formed a symptomatic pseudocyst. This was drained endoscopically by placing a lumen-apposing metal stent. Unfortunately, she developed gastric perforation requiring surgery. The patient was noted to have persistent gastric fistula in the posterior stomach wall communicating with the pancreatic bed. This was too big for over-the-scope clip application, and endoscopic suturing failed to heal the fistula. We then employed the polyloop anchor technique using multiple endoclips for fistula closure.
A polyloop device was introduced inside the stomach beside a gastroscope and was opened fully. The polyloop was secured along the margins of the fistulous opening starting with the most distal end. Multiple endoclips were then used to manipulate and secure the polyloop along the margins. Once an adequate number of anchor points were secured, the polyloop was closed slowly under direct endoscopic visualization. Two months later an upper GI study demonstrated no leakage of contrast. Follow-up EGD and CT scan confirmed healing of fistula.
Gastrointestinal tract perforations larger than a 1 cm are usually not amenable to over-the-scope clip placement. Endoscopic suturing has gained popularity in closing larger perforations; however, it may not be as successful as in our patient. The polyloop anchor technique has been reported for fistula closure, but it is not widely known; hence, we saw an opportunity to demonstrate the procedure via video.
Other endoscopists may consider the polyloop anchor technique as an alternative to endoscopic suturing for treating large perforations in the stomach, distal colon, and rectum. The video demonstrates technical details pertaining to positioning and anchoring the polyloop device. Treating fistula margins with APC prior to loop-assisted closure may promote fistula healing. Given technical challenges in maneuvering the polyloop device while it is outside the scope makes this less feasible for closing fistulas in the proximal colon.
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