Endoscopic Closure of Gastric Fistula After Bariatric Surgery Using the Over-the-Scope Clip (OTSC): A Case Report

Abstract

Background:

A gastric fistula (GF) is defined as an abnormal communication between the gastric mucosa and an adjacent anatomical structure.

Case Presentation:

We report a 30-year-old male patient who developed a subcardial gastric fistula after sleeve gastrectomy. It was successfully treated using the Over-the-Scope Clip (OTSC) system as a non-surgical approach.

Conclusion:

This case demonstrates the effectiveness and feasibility of the over-the-scope clip device for closure of post-bariatric gastric fistulas and highlights its applicability when surgical intervention carries significant risks.

Introduction

A gastric fistula (GF) is defined as a pathological tract that establishes communication between the epithelialized mucosa of the stomach and another anatomical structure. In adults, GF most frequently develops in the setting of malignant gastric disease; however, it may also occur as a postoperative complication—particularly after bariatric procedures—or arise secondary to trauma, infection, or chronic inflammatory processes. ¹  The incidence of gastric fistulas after Roux-en-Y gastric bypass is reported between 1% and 6%. ²

The clinical manifestations of gastric fistula vary according to its etiology and location. Common symptoms include nausea, vomiting, fever, and epigastric pain; this condition may also be associated with marginal ulcers.^3,4

Gastric fistulas are generally classified as internal (abnormal communication between the GI tract and an internal space) and external (connection between the GI tract and the skin surface). ⁵  They may also be classified by etiology, anatomy, and output volume: low-output (<500 mL/day) or high-output (>500 mL/day). ⁶

Understanding the etiology, anatomical characteristics, and location of a gastric fistula is essential, as these factors significantly influence the likelihood of successful endoscopic closure. While high-output fistulas are readily identified through imaging studies, the decision to pursue endoscopic therapy is not determined solely by output volume. ⁷  Endoscopic closure of gastric fistulas has been investigated for more than a decade, with the over-the-scope clip (OTSC) system demonstrating promising outcomes, achieving an initial closure rate of 81.1%. ⁸

The over-the-scope clip (OTSC) system is a hemostatic endoscopic device that was initially introduced for the management of non-variceal gastrointestinal bleeding. Made of elastic nitinol, it achieves complete closure by approximating tissue and was FDA-approved in 2010. Unlike standard through-the-scope (TTS) clips, OTSC can close defects larger than 2 cm in a single application.^9,10

Herein, we present our clinical experience using OTSC to close a gastric fistula following bariatric surgery.

Case Presentation

A 30-year-old male presented with a 1-week history of abdominal pain, fever, and intolerance to oral intake. His medical history was notable for obesity and hypertension, and he had undergone a sleeve gastrectomy 7 days earlier. On examination, he was tachycardic and tachypneic, with localized tenderness in the epigastrium and left hypochondrium. Initial laboratory tests revealed leukocytosis with a left shift and elevated acute-phase reactants. Computed tomography (CT) imaging demonstrated a small left pleural effusion and a subphrenic abscess. Upper endoscopy revealed a 1 cm posteromedial mucosal defect in the subcardial region, located 5 cm distal to the gastroesophageal junction, consistent with a gastric fistula. (Figure 1).

Figure 1.

Endoscopic view of the sub-cardial region with sub-cardial fistula (black arrow), above the gastroesophageal junction (white arrow).

Initial non-operatory management, including nil per os, antibiotics, and parenteral nutrition, was unsuccessful. The patient subsequently underwent endoscopic placement of an over-the-scope clip (OTSC) using a Fujinon 250 gastroscope equipped with a pre-mounted device. (Figure 2 ). At 48 hours, endoscopy confirmed correct clip placement and complete closure of the fistula. (Figure 3). No leakage or complications were observed. The patient recovered and was discharged with favorable outpatient follow-up.

Figure 2.

Endoscopic view of sub-cardial fistula with OTSC device (black arrow), above the gastroesophageal junction (white arrow).

Figure 3.

Endoscopic view of sub-cardial fistula closed with OTSC Clip, above the gastroesophageal junction (white arrow).

Discussion

This case describes the successful management of a subcardial gastric fistula following sleeve gastrectomy using the OTSC system, demonstrating its role as a non-surgical alternative. Gastric fistulas after sleeve gastrectomy occur in 0.5% to 6% of cases and are often accompanied by abscess or pleural effusion.^1-3

Endoscopic OTSC closure offers a less invasive option, potentially reducing reoperation rates and improving outcomes. ³  Compared to expandable stents, which have migration rates up to 47% and ulceration rates of 41% OTSC shows fewer complications.^1,2

Mosquera-Klinger et al. reported a technical success rate of 100% and a clinical success rate of 78.6% in gastrointestinal perforations treated with OTSC in a tertiary center. ¹  In Bogotá, a 2015 case series reported an 83.3% success rate in various GI lesions, including post-bariatric gastric fistulas. ⁹

These outcomes align with our findings. Factors such as early detection and timely intervention significantly enhance success rates. However, further large-scale studies are needed to evaluate long-term results, cost-efficiency, and help create evidence-based guidelines for OTSC use in this context.

Conclusion

The over-the-scope clip represents a safe and effective minimally invasive alternative to surgical re-intervention in post-bariatric gastric fistulas. However, broader studies are needed to establish its role as a first-line therapeutic option.