Post written by Sagar Shah, MD, Adarsh Thaker, MD, and Alireza Sedarat, MD, from the Vatche and Tamar Manoukian Division of Digestive Diseases, Ronald Reagan UCLA Medical Center, Los Angeles, California, USA.

Our video submission highlights 2 cases of persistent gastrocutaneous fistulas (GCFs) after removal of long-term PEG tubes. In both patients, the fistula tract failed to close spontaneously and led to ongoing leakage that negatively affected quality of life.

Traditional options such as surgical closure carry higher risk, but prior endoscopic attempts using over-the-scope clips (OTSCs) or suturing devices alone have been associated with incomplete closure or recurrence. In these cases, we combined 2 complementary techniques: tack suturing to approximate the tissue and reduce the size of the defect, followed by OTSC placement to seal the tract. Both patients tolerated the procedure well, resumed oral intake the following day, and remained free of leakage during follow-up.

Persistent GCFs can be a challenging situation and may require multiple procedures, perhaps because of insufficient tissue capture or grasp from a single-device approach. Although OTSCs and suturing devices are well described individually, their sequential use has not been widely demonstrated, to our knowledge. We felt it was important to showcase this approach because it features how combining existing endoscopic tools can address the limitations of each therapy when used alone.

With first reduction of the size of the fistula opening with tack sutures, the subsequent OTSC can capture and secure the defect more effectively, resulting in more durable closure. We hope sharing this video case series allows other endoscopists to appreciate the technique’s versatility and perhaps inspires further innovation.

Management of chronic GCFs need not be limited to surgery or single-modality endoscopic interventions. Our cases demonstrate that strategic combination therapy can enhance closure success while remaining minimally invasive. Equally important, the choice of OTSC type and deployment method should be tailored to the clinical context—clips deployed with a beside-the-scope cable allow simultaneous use of tack suturing, whereas channel-deployed clips provide greater flexibility in clip size and shape. By considering these nuances and integrating techniques, endoscopists can expand the range of therapeutic options offered for patients with persistent GCFs.

Use of through-the-scope tack suturing device within over-the-scope clip cap.

Read the full article online.

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