Endoscopic closure of a large gastrogastric fistula. We don't have any disclosures. The rise in bariatric and other surgical procedures has led to an increased incidence of GI fistulas. While surgical management was initially the standard of care, endoscopic therapies have since emerged, offering improved outcomes. However, endoscopic fistula closure remains particularly challenging, especially in cases with large defects. We present the successful closure of a remarkably large gastrogastric fistula in a patient with a history of gastric bypass surgery. A 46-year-old male with a history of morbid obesity, hypertension, and gastric bypass surgery 20 years ago was being evaluated for difficulty of losing weight. Further evaluation, including imaging, revealed the presence of a GI fistula. The patient was referred for assessment, possible fistula closure, and consideration of a transoral outlet reduction endoscopy procedure. The patient underwent EGD to evaluate the fistula previously seen on imaging. The anatomy was consistent with gastric bypass. A large 15-centimeter fistula connecting the gastric pouch to the excluded stomach was identified. The rim of the fistula was treated with organ plasma coagulation, promoting granulation tissue formation and enhancing the healing response. Sutures were placed circumferentially along the edges of the fistula to draw the margins together and ensure a tight closure. Puristat was dispensed via a catheter and distributed evenly over the closure site, promoting cell proliferation and wound healing. The patient underwent an EGD to evaluate the anatomy and locate the fistula. A large 15-centimeter fistula was identified connecting the gastric pouch to the excluded stomach. An APC catheter was then mounted on the scope. The rim of the fistula was carefully treated using APC to promote granulation tissue formation and enhance the healing response. Then, using an overstitch device, five different sutures were placed circumferentially around the fistula. These sutures were then all tightened at the end to ensure a secure closure. Pirasta was applied over the suture site and evenly distributed to support cell proliferation and wound healing. The area was re-examined endoscopically to confirm adequate closure and ensure there was no residual fistula or leakage. That's before and after where we can see complete fistula closure. To date, no clear guidelines exist for fistula management, and determining the optimal treatment strategies for these complex cases remains challenging. We present the successful closure of a remarkably large gastrogastric fistula using a combination of thermal therapy and suturing. This case highlights the importance of a patient-tailored approach in managing complex fistulas on a case-by-case basis.

bariatric surgery

endoscopic therapy

gastrointestinal fistula

gastrogastric fistula

personalized treatment