The OTSC “Bear Claw” - A Novel Technique for Gastrocutaneous Fistula Closure: The First North American Experience

Abstract

Purpose: Background: The mainstay of therapy for Gastrocutaneous (GC) fistulas has been surgical intervention. Routine endoscopic methods to close GI perforations currently used for management of perforations and fistula are not satisfactory due limitations. The Over the Scope Clip-OTSC system (OTSC(R)); is a new tool for the endoscopic entrapment of tissue. We present a case of an iatrogenic fistula successfully treated with the OTSC system for the first time in North America. Case: An 80 year old female presents with a long standing GC fistula. The patient had originally undergone a trans-esophageal echo (TEE) which resulted in an esophageal perforation. Post-surgical repair included placement of a feeding jejunostomy and venting gastrostomy tube. Subsequently the patient redeveloped the ability for oral diet, however despite extensive medical therapy, the GC fistula persistently drained after removal of the gastrostomy tube for 9 months. The OTSC system is composed of an application cap, which is mounted onto the distal tip of the endoscope and a connected releasing mechanism, installed on the handle of the scope. Two different variants of the clip, consisting of a shape-memory alloy (nitinol) are available: the “traumatic” and the “atraumatic” versions. There are two proprietary devices to draw the tissue into the cap; a tissue grasper or tripod device. The clip is deployed by stretching a wire with a hand wheel fixed on the access of the endoscope working channel. An Olympus endoscope was introduced through the mouth and advanced down to the level of a hiatal hernia sac where previously placed surgical sutures, esophageal perforation repair, were seen adjacent to the GEJ. The greater curvature revealed a retracted mucosal surface in continuity with the gastrostomy site on the outer abdominal wall. A savory guide wire was passed through the GC fistula through the abdominal wall and into the stomach. The scope was withdrawn and the OTSC system is mounted on the tip of the scope. The scope was passed to the level of the fistula. The targeted site of the fistula was grasped with the tripod device and brought into the cap. The Bear claw was deployed in excellent position. A second Bear claw device was deployed in the left aspect of the previously placed Bear claw. The savory wire was attempted to be passed through the skin into the stomach however couldn't be passed with Bear claw in position. Conclusion: Several case series have demonstrated the superiority of fistula closure via the OTSC system. This is the first case in North America to employ the system. We recommend the OTSC system for hemostasis, compression of large vessels, and closure of perforations and fistulas of the GI tract.