Post written by Arunkumar Krishnan, MBBS, from the Section of Gastroenterology and Hepatology, West Virginia University School of Medicine, Morgantown, West Virginia, USA.

We demonstrate a technique for the closure of pancreatocolonic fistulae (PCF) using an X-Tack Endoscopic HeliX System (Apollo Endosurgery, Austin, Tex, USA).

GI tract fistulation is an uncommon but important consequence of acute necrotizing pancreatitis. Devices available for mucosal closure include through-the-scope clips (TTSCs), over-the-scope clips (OTSCs), and endoscopic suturing.

However, each device has benefits and associated limitations. Our video case demonstrates a patient with walled-off pancreatic necrosis complicated with PCF that a novel endoscopic method closed using the helical-tack system.

OTSCs are limited by the need for endoscope removal for loading and reinsertion to the target site, which may be challenging for fistulae at difficult locations. They may not suit fistulae with friable margins, which serve as poor anchor sites.

In contrast, endoscopic closure using conventional TTSCs is often limited by the need for optimal positioning to achieve adequate tissue apposition, and it requires multiple clips for larger defects.

Importantly, we treated the fistulous tract using argon plasma coagulation (APC) to promote scarring, encourage granulation tissue formation, and aid in tissue apposition.

Hence, mucosal apposition from the APC-induced scarring and the suturing system likely contributed to closure success, along with the presence of the percutaneous drain.

In conclusion, the new helical-tack system permits maneuverability and approximates defects by anchoring into healthy tissue without endoscope withdrawal.

In addition, this novel helix tack system may be especially suitable in the proximal colon, where access by other closure devices can be challenging.

Fistula site following endoscopic closure using the helix tack suturing system.

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