Successful Closure of a Suture Line Leak Following Remnant Gastrectomy in a Patient With Gastrogastric Fistula Using an Over-the-Scope Clip

Abstract

Introduction: In the past, treatment of gastrointestinal leaks was primarily surgical. Recently, endoscopic over the scope clip (OTSC) has been used to treat these defects. We report a case of a suture line leak following remnant gastrectomy that was successfully closed using an OTSC. Remnant gastrectomy was done to close a fistula that developed between the stomach pouch and the remnant stomach in this patient who had a remote history of gastric bypass. Case Report: Fifty-year-old white female who underwent a gastric bypass with a revision in 1998 developed gastrogastric fistula in 2013. Laparoscopic excision of the remnant stomach was done to close the fistula. She presented with fever and left sided chest pain 2 weeks after surgery. Upper GI series revealed extravasation of contrast from the stomach into the left upper abdomen. CT abdomen revealed an abscess in the left upper abdomen and left sided pleural effusion which were drained. EGD revealed 3 openings in the stomach pouch. The largest of these openings measured 10 mm through which the catheter draining the abscess was visible. Two 10 mm OTSCs were deployed successfully closing these openings. Follow-up CT abdomen 1 month later showed resolution of the abscess and no evidence of leak. Patient felt well at 5 months follow-up. Discussion: OTSC is a new endoscopic device that has been used for closing gastrointestinal leaks. Most of the reported cases of OTSC use for leak are for the lower GI tract. There are few case reports of OTSC use in upper GI leaks mainly for esophagogastric, gastroenteric anastomotic leaks and suture dehiscence following sleeve gastrectomy. We report the first case of suture line leak following remnant gastrectomy that was successfully closed using OTSCs. Our case was also unique in that there were 3 sites of leak that were successfully closed using 2 OTSCs in one session. Thus, OTSC can be a less invasive and cost effective leak repair technique compared to surgery in patients with a high risk of recurrence. Success rate of OTSC for anastomotic leak is lower (50-100%) than for perforation or bleeding (71-100%). Very early leaks occurirng within a week, leak size of 10 to 30 mm and prior abscess drainage are associated with successful closure of leaks. Our case reiterates this fact.Figure 1: OTSC placement.