V5 - Suture Traction-Assisted Bearclaw Fistula Closure: A Case Series Describing a Novel Endoscopic Technique for Fistula Closure

Joelle Sleiman, MD, Mohammad Abureesh, MD, Jean M. Chalhoub, MD, Sherif Andrawes, MD, Youssef El Douaihy, MD
Staten Island University Hospital, Northwell Health, Staten Island, NY

Introduction: Endoscopic therapies are currently the mainstay of treatment of gastrointestinal (GI) fistulas. However, some GI fistulas are difficult to close due to the tissue's friability and large-size defect. This case series describes a novel technique for managing hard-to-treat fistulas.

Case Description/Methods: Endoscopic Method

Utilizing an endosuturing device, we strategically obtain full-thickness bites at various points surrounding the fistula opening. These sutures are intentionally left untightened, remaining loose within the GI tract. Subsequently, the scope is withdrawn, leaving the sutures extending outside the patient. These deep tissue bites serve as robust anchoring points for traction and facilitate the creation of a flap. In employing a dual-chamber scope, the suture threads are grabbed through one of the scope channels using a snare, and an Ovesco clip is mounted on the scope. The endoscope is reintroduced. Traction is then applied to the suture threads, allowing healthy bowel tissue to be drawn outside the fistula, forming a flap. Once an adequate quantity of tissue is obtained and the fistula tract is no longer visible, the over-the-scope clip is deployed, creating an occlusive patch, and effectively sealing the fistulous tract.

Cases Presentation

We present 3 cases of GI fistulas that failed to close using traditional endoscopic techniques. The first case is that of a 78-year-old man with a history of bladder cancer treated with radical cystectomy and neobladder construction, as well as a long history of ulcerative colitis resulting in a recto-vesicular fistula. The second patient is a 68-year-old man with a history of gastric cancer treated with partial gastrectomy and gastrojejunostomy complicated by jejuno-colonic fistula formation. The third patient is a 30-year-old man with a history of cerebral palsy, who relies on enteral feeding via jejunostomy, with gastro-cutaneous fistula formation at the previous percutaneous endoscopic gastrostomy tube site. Successful fistula closure was achieved using this novel technique without complications or recurrence in all 3 cases.

Discussion: We presented 3 successful applications of this novel technique, each with a 9-13 month follow-up showing no recurrence or complications. This technique involves using deep tissue bites to enable traction of the mucosa without causing damage, facilitating the formation of a flap with sufficient tissue for clip deployment. It offers a promising solution for challenging fistulas that resist closure with standard procedures.


Disclosures:


Joelle Sleiman, MD, Mohammad Abureesh, MD, Jean M. Chalhoub, MD, Sherif Andrawes, MD, Youssef El Douaihy, MD, V5, Suture Traction-Assisted Bearclaw Fistula Closure: A Case Series Describing a Novel Endoscopic Technique for Fistula Closure, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.