Endoscopic closure of a refractory gastrocutaneous fistula using a novel over-the-scope Padlock clip following de-epithelialisation of the fistula tract

Endoscopic removal of a weight-loss device with stoma closure using a tack-and-suture device

Video 1.

Endoscopic Management of Postoperative Esophageal and Upper GI Defects-A Narrative Review

Anastomotic defects are deleterious complications after either oncologic or bariatric surgery, leading to high morbidity and mortality. Besides surgical revision in early stages or instable patients, endoscopic treatment has become the mainstay. To date, many options for endoscopic treatment in this setting exist, including fully covered metal stent placement, endoscopic vacuum therapy (EVT), endoscopic internal drainage with pigtail placement (EID), leak closure with through the scope or over the scope clips, endoluminal suturing, fibrin glue sealing and a combination of all these techniques. Current evidence is mostly based on retrospective single and multicenter studies. No guidelines exist in this important field. Treatment options have to be chosen upon each case individually, taking into account clinical and anatomic criteria, such as timing, size, infectious wound complications and hemodynamic stability. Local expertise and availability of treatment devices need to be taken into account whenever choosing a treatment strategy. This review aimed to present current treatment options in terms of effectiveness, advantages and disadvantages in order to guide the clinician for his decision making. Additionally, we aimed to provide a treatment algorithm.

Prevention and management of major complications in percutaneous endoscopic gastrostomy

Background

Percutaneous endoscopic gastrostomy is a commonly used endoscopic technique where a tube is placed through the abdominal wall mainly to administer fluids, drugs and/or enteral nutrition. Several placement techniques are described in the literature with the ‘pull’ technique (Ponsky-Gardener) as the most popular one. Independent of the method used, placement includes a ‘blind’ perforation of the stomach through a small acute surgical abdominal wound. It is a generally safe technique with only few major complications. Nevertheless these complications can be sometimes life-threatening or generate serious morbidity.

Method

A narrative review of the literature of major complications in percutaneous endoscopic gastrostomy.

Results

This review was written from a clinical viewpoint focusing on prevention and management of major complications and documented scientific evidence with real cases from more than 20 years of clinical practice.

Conclusions

Major complications are rare but prevention, early recognition and popper management are important.

Over-the-Scope Clip Closure of Persistent Gastrocutaneous Fistula After Percutaneous Endoscopic Gastrostomy Tube Removal: A Report of Two Cases

Persistent gastrocutaneous fistulas have conventionally been treated surgically. Over-the-scope clip (OTSC) was developed as an endoscopic closure device for full-thickness gastrointestinal defects and has become one of the treatment options for gastrocutaneous fistula. Herein, we report two cases of gastrocutaneous fistulas treated using OTSC. Case 1 was a 71-year-old woman and case 2 was an 88-year-old man, both of whom had severe frailty and had a persistent gastrocutaneous fistula after removal of the percutaneous endoscopic gastrostomy (PEG) tube. OTSC closure was chosen over surgical closure to reduce invasiveness. In case 1, OTSC was deployed using a suction method, which was technically successful. However, the fistula reopened two days later, indicating clinical failure of the OTSC. The cause of the failure may be due to an inadequate suction of the fistula into the applicator cap. Based on the experience of OTSC failure in case 1, OTSC in case 2 was deployed using the Anchor to pull the fistula into the cap more reliably. Fistula did not recur during the 30-month follow-up, indicating the clinical success of OTSC in case 2. The use of Anchor may increase the success rate of OTSC, but there is a dilemma that the use of Anchor increases cost. In summary, OTSC has the advantage of being less invasive compared to conventional surgery; however, the application of OTSC for chronic fistulas remains challenging due to issues regarding clinical success rate and cost.