Bridging the Gap to Surgery, Endoscopic Management of a Massive Gastrocolic Fischula. Gastrocolic fischulas are a rare but devastating complication of abdominal radiation therapy. Management of gastrocolic fischulas consists of primary surgical on-block resection, however cases of endoscopic closure have also been reported. Endoscopic management of gastrocolic fischulas have been reported using through-the-scope and over-the-scope clips. While these methods may be temporarily effective in the closure of small fischulas, endoscopic closure of large fischulas are unlikely to be achieved. We present a novel method of gastrocolic fischula closure using a combination of endoscopic stenting and endoscopic suturing as a bridge to definitive surgical management. A 50-year-old woman with a history of recurrent metastatic pleomorphic leiomyosarcoma was admitted for abdominal pain and diarrhea. The patient had a history of primary retroperitoneal mass resection and abdominal radiation therapy two years prior. Contrast enhanced imaging of her abdomen and pelvis demonstrated gastric wall thickening and a loss of fat plane between the gastric wall and the transverse colon. CT scan shows gastric wall thickening and a loss of fat plane between the stomach and transverse colon as demonstrated by the red arrows. An EGD was performed and revealed two massive gastrocolic fischulas in the antrum communicating with the transverse colon. A colonoscopy was then performed and re-demonstrated a large fischula communicating with the stomach and adjacent to this, a colonic stricture nearly obstructing the proximal colon. Biopsies of the fischula were obtained and pathology demonstrated ulceration with reactive epithelial atypia and foveolar hyperplastic changes but no definitive malignancy. Seen here is the index EGD revealing a gastrocolic fischula leading into the transverse colon. The case was discussed at the multidisciplinary GI surgical oncology conference. The initial treatment options discussed included primary surgical resection, however, this was felt to be too high risk given the patient's poor nutritional status. Additionally, TPN with total bowel rest was considered, however, this fails to address her diarrhea and regurgitation of colonic contents. Finally, a decision was made to proceed with fully covered metal stent placement, stent suturing to prevent migration, and possible endoscopic suturing of the gastrocolic fischulas in order to re-establish GI tract continuity. Repeat colonoscopy showed a fischula at the descending colon that was able to be traversed and the stomach was entered. On the right, the pylorus was seen and on the left, the G-junction was visualized. The pylorus was then intubated and the duodenum was examined. Tension was then turned to the colonic stricture adjacent to the fischula. A wire was then placed across the stricture but appeared to re-enter the stomach, suggesting the second gastrocolic fischula was proximal to the colonic stricture. The stricture was then dilated using a through-the-scope balloon and the colonoscope was then able to traverse the stricture and re-enter the stomach. Attention was then returned back to the level of the stricture where a second colonic stricture was noted as seen by the red arrow. The second colonic stricture was able to be traversed with mild resistance and access to the proximal colon was obtained. The remainder of the proximal colon appeared normal. Next, a wire was placed into the proximal colon across the stricture and a 20mm by 15cm fully covered metal stent was placed under fluoroscopic and endoscopic guidance across the stricture. The stent appeared to be in good position and next the stent was sutured in place using a helix tack device. The proximal portion was sutured in a stent-mucosa-stent-mucosa fashion. A total of four tacks were placed on the proximal portion suturing the stent into place. Suturing was then repeated at the distal aspect in a similar fashion where a total of eight tacks were placed securing the stent into position. Next EGD revealed the two gastrocolic fistulas with the fully covered metal stent patching the two openings of the gastrocolic fistulas. Next a full thickness endoscopic suturing device is used to secure the stent into place and the gastrocolic fistula is sutured in a continuous pattern. On cinching, one can appreciate a great degree of tissue apposition. The stent is then secured at the second gastrocolic fistula and endoscopic suturing of the gastrocolic fistula is performed in a similar fashion. At completion of the suturing, the final cinch is deployed and on repeat inspection, both the gastrocolic fistulas appear closed and an NJ tube was endoscopically placed. Following the procedure, the patient had an immediate resolution of her diarrhea. Final supplementation was started via her NJ tube and an upper GI series was obtained and showed no evidence of a leak across the gastrocolic fistulas. The patient began to tolerate a full liquid diet. Upper GI series demonstrated contrast passing into the stomach without evidence of a leak at the level of the gastrocolic fistulas and KUB demonstrated contrast passing into the distal colon. On two week follow-up, the patient continued to tolerate a liquid diet. The patient's NJ tube was removed and plans were made for PEGJ placement in order to optimize her nutritional status prior to definitive surgical management. Using a combination of endoscopic stenting and suturing, GI tract continuity was reestablished. Fully covered metal stents can be used in the colon in select cases and can be sutured to prevent migration using 3D scope helix tacks without a need to withdraw the clonoscope. A fully covered metal stent was successfully placed across the colonic stricture while simultaneously patching the two gastrocolic fistulas. Using a suturing device in the stomach, the stent was able to be secured and full thickness closure of the fistulas were achieved. Multidisciplinary collaboration can provide effective management options in patients who are poor upfront surgical candidates. Closing the patient's gastrocolic fistulas using a combination of endoscopic stenting and suturing reestablished GI tract continuity, allowing for optimization of the patient's nutritional status prior to surgery. Our case demonstrates that gastrocolic fistula closure using a combination of endoscopic stenting and suturing serves as a feasible and effective bridge to definitive surgical management.

gastrocolic fistulas

abdominal radiation therapy

surgical resection

endoscopic closure

endoscopic stenting