Enterocutaneous Fistula Plug Placement as a Successful Endoscopic Intervention for Management of a Refractory Gastrocutaneous Fistula: ACG Clinical Vignette Award Presidential Poster

Abstract

Introduction: Chronic gastrocutaneous fistulae (GCF) can tremendously impact patients’ health and quality of life. Multiple endoscopic interventions have been reported to assist in GCF closure including clips, cyanoacrylate, tissue adhesives, and endoscopic suturing. Porcine small intestine submucosa (SIS) Biodesign® Enterocutaneous Fistula Plug (EFP) (Cook Medical, Bloomington, IN) is designed to assist with the closure of enterocutaneous fistulae. We report this case to share our experience of using this device for the closure of a refractory GCF. Methods: A 46-year-old female developed a splenic abscess 7 months after sleeve gastrectomy, requiring laparotomy with splenectomy and percutaneous drain placement that led to formation of a GCF. A partially covered esophageal stent was placed at an outside hospital to aid with closure. Retrieval attempt 2 months later was unsuccessful due to robust tissue ingrowth. Upon referral to our medical center, 2 overlapping fully covered stents were placed inside the partially covered stent with 1-2 cm of overlap on the distal and proximal ends with the intent of causing pressure necrosis on ingrown tissue to facilitate removal of the partially covered stent. All 3 stents were removed after 2 weeks; the fistula was observed in the proximal stomach about 15 mm distal to the GEJ. Surgical consultation was obtained but surgical repair was declined. At a subsequent EGD, the GCF tract was abraded with a brush and treated with Argon Plasma Coagulation for de-epithelialization. Over-the-scope clip (OTSC, Ovesco Endoscopy USA, Los Gatos, CA) closure was then performed with apparent technical success. Unfortunately, the fistula continued to drain and this persisted for few months; as such, closure with the Biodesign EFP was elected. After tract dilation, a 22 Fr Wilson Cook Biodesign® EFP was passed over the guidewire and deployed into the tract, with good seating of the internal retention disk confirmed endoscopically. Results: The patient had no further fistula drainage and the external aspect of the fistula was noted to be well-healed at a follow-up office visit one month later. Conclusion: Leaks leading to formation of fistulous tracts are a known complication after bariatric surgery. Insertion of porcine SIS to facilitate closure has been reported in cases of refractory enterocutanoeous and perinanal fistulae. A SIS product developed specifically for enterocutaneous fistulae has recently been developed and FDA approved. In our case, this wire-guided SIS EFP was successful in closing a chronic GCF when other modalities had failed.