Endoscopic Wire-Assisted Closure of Enteric Fistulae

Abstract

Introduction:

Historically, the treatment of enteric fistula required surgical intervention, often exposing patients to complex surgeries and a high risk of fistula recurrence. With advancements in endoscopic therapies, successful closure of enteric fistula using over-the-scope (OTS) clips can be as high as 85%. ¹ A previous study demonstrated the safety and efficacy of firing OTS clips over a wire, which allows the endoscopist to improve the maneuverability of the endoscope and obtain appropriate apposition of the OTS clip to the fistula opening. ² This video documents two obscure enteric fistulae and the use of a flexible guidewire to facilitate the application of an OTS clip. We demonstrate that firing an OTS clip over a wire is safe, with easy removal of the wire following clip placement.

Materials and Methods:

Case A: The first patient has a history of gastric bypass requiring multiple revisions and developed a jejunocutaneous fistula. Upper endoscopy was performed, and wire access was obtained across the fistula tract. The endoscope was backloaded onto the wire. Once the endoscope was adjacent to the fistula opening, traction placed on both ends of the flexible wire helped obtain an appropriate apposition between the tip of the endoscope and the fistula opening. A 12/6 T-type OTS clip was fired over the wire to close the enteric side of the fistula tract. Once the clip was successfully deployed, the wire was removed intact and with ease. The fistula tract was ablated from the cutaneous side using argon plasma coagulation. Case B: This patient developed a persistent gastrocutaneous fistula at the site of a previous gastrostomy tube. Similar to the first case, an upper endoscopy was performed, and wire access was obtained across the fistula tract. Traction on the wire brought the endoscope tip into apposition with the fistula opening before firing a 12/6 GC-type OTS clip. Once the placement of the OTS clip was confirmed, the wire was removed from the skin intact and with ease.

Results:

Case A: Following the initial OTS clip placement, the fistula recurred almost immediately. A repeat endoscopy showed that the initial clip was no longer in place. Another 12/6 T-type OTS clip was placed, this time without wire assistance. The patient had a recurrence of drainage from the fistula a few weeks after the procedure. The patient was lost to follow-up after moving out of state. Case B: The postoperative course was unremarkable, and the fistula closed successfully.

Conclusion:

A flexible guidewire is a useful adjunct to appropriately position an endoscope for proper OTS clip placement to treat enteric fistulae. It is safe to fire an OTS clip over a wire without compromising the wire or preventing its removal.

Disclosures:

Eric D. Moyer and McKell Quattrone have no relevant disclosures. Eric M. Pauli has speaking/teaching appointments with Ovesco Endoscopy.

Consents:

Author(s) have received and archived patient consent for video recording/publication in advance of video recording of the procedure.

Runtime of video: 7 mins 14 secs.