Endoscopic Closure of Gastrocutaneous Fistulas Using Over-The-Scope Clip (OTSC®): A Case Series

Abstract

Purpose: Persistently leaking gastrocutaneous fistula (GCF) may develop as a complication secondary to gastrostomy tubes. GCF's have been conventionally managed surgically. Endoscopic closure techniques have shown limited success. In this prospective study we have evaluated the efficacy of OTSC's in management of chronic GCFs. Methods: This prospective observational study enrolled patients with persistently leaking GCF's as a complication of gastrostomy tube. As per protocol, patients were initially managed by NPO, acid suppression and antibiotics (in case of suspicion of infection) for 3 days in an attempt for spontaneous closure. If there was persistent leakage an endoscopy was performed to access the gastric stoma of the fistula. Endoscopic closure using OTSC® (Ovesco, gc type 12/6) was planned if the fistula was determined unlikely to heal spontaneously based on the endoscopist's assessment. The suctioning technique was used to deploy the OTSC® in all cases. An endoscopic gastrostomy tube was placed at a new healthy site in all cases and feeding was started in 24 hours. All subjects were followed for recurrence of leakage at the GCF site. Results: Eight consecutive cases with GCF were enrolled into the study. Mean age of study subjects was 84.7 years. Five patients had cellulitis at GCF stoma site. Three patients had prior failed attempts for endoscopic fistula closure using standard clips. Clinical success rate for GCF closure using OTSC® was 7/8 (87.5%). Six patients needed single OTSC® for GCF closure. One patient had recurrence of leakage from the site after one month, from a small gastric stoma defect adjacent to a previous OTSC®. This was managed with placement of an additional OTSC®. Another patient had persistent leakage after OTSC® placement and repeat attempt of applying OTSC® was unsuccessful because of extensive fibrosis. No technical difficulties or complications were experienced. None of the patients with successful closure had leakage from GCF until the end of follow up (range 1-17 weeks). Conclusion: Over-The-Scope Clips (OTSC®) have an excellent success rate for closure of gastrocutaneous fistulas in selected cases. Successful endoscopic closure is likely to prevent morbidity associated with surgical procedure and length of hospital stay.