This ASG video tip is brought to you by an educational grant from Braintree, a part of Cibela Pharmaceuticals, makers of SUTAB. Cardiac septal occluder for treatment of gastro-gastric fistula. Closure of a chronic gastro-gastric fistula after room-wide gastric bypass. These are our disclosures. Gastro-gastric fistula is an abnormal communication between the gastric pouch and remnant stomach that may develop as a complication of room-wide gastric bypass. This breakdown of the stable line and fistula formation may occur in as many as 6% of patients after traditional bypass and results from incomplete division or transection of the gastric pouch during the initial surgery due to a marginal ulceration, form body erosion or as a result of a chronic anastomotic leak. Patients classically present with worsening reflux abdominal pain, marginal ulcers due to increased acid exposure or weight regain. While diagnosis primarily relies upon upper GI series, endoscopic management can be challenging for chronic fistulas larger than 1 cm due to epithelialization of the tract. Multiple studies have shown limited success with conventional endoscopic approaches, most often requiring patients to undergo surgical revision and closure. However, off-label use of the cardiac septal defect occluder device has recently been shown to be effective for gastrointestinal leaks in fistula. This device is a self-expanding, double-disc device approved for closure of atrial and ventricular septal defects. It is composed of nitinol and interwoven polyester to promote occlusion and tissue ingrowth, making it an ideal candidate for closure of chronic fistulas within the GI tract. In this video, we describe a case of a 47-year-old woman with a history of room-wide gastric bypass in 2012 who presented to our institution with postprandial abdominal pain, worsening heartburn symptoms, and weight regain. Given the high suspicion for a gastro-gastric fistula, she underwent a barium swallow, shown here, which demonstrated contrast freely passing into the remnant stomach, confirming the presence of a gastro-gastric fistula. In this initial endoscopy, we see a dilated gastrojejunal anastomosis, measuring 35 mm, and the presence of a gastro-gastric fistula at the 10 o'clock position, measuring approximately 12 mm in diameter. The gastro-gastric fistula could easily be traversed with a standard gastroscope, but the remnant stomach evaluated, as shown here. The scope is then withdrawn back into the gastric pouch, and preparations are then made for endoscopic fistula closure, including attachment of a distal translucent cap. The first step for endoscopic treatment of a chronic gastro-gastric fistula involves treatment with argon plasma coagulation, or ABC, typically at a higher wattage of 60-70 watts, to de-epithelialize the tract. Here we are applying forced coagulation ABC at 70 watts in a circumferential pattern around the fistula site. If the fistula is small, endoscopic brushing can also be utilized in an attempt to achieve de-epithelialization of the tract to assist in closure of the fistula. When endoscopic suturing has been directly compared to surgical revision for the closure of gastro-gastric fistulas, surgical treatment has demonstrated a higher efficacy. However, it has also been associated with a greater risk of adverse events. Now shown in this video is the construction of a delivery system for the cardiac septal occluder. At our institution, we first utilize the 10-inch biliary catheter, or sheath, as a delivery mechanism for the occluder. Pediatric biopsy forceps are then placed down the catheter and used to grasp the post on the open cardiac septal defect occluder. Choosing the optimal size of the occluder is critically important. With recommended occluder diameter being at least 50% larger than the diameter of the fistula's tract, it is important that the cardiac septal defect occluder be aligned properly and the forceps well secured to the post prior to withdrawing the device back into the biliary catheter. Once this is attached, you can see the delivery mechanism nicely demonstrated in this video, with the distal phalange and proximal phalange deployed and withdrawn back into the biliary catheter. These videos highlight this simple modified delivery system through the working channel of the endoscope. We can see nicely the deployment outside of the body from a side and forward view, replicating the exact steps that will be taken to effectively close the gastrogastric fistula when introduced into the patient. Now we see the biliary catheter and modified delivery system traversing the chronic gastrogastric fistula, again noting our first step of treatment with APC to deepithelialize the tract. Close inspection of the catheter reveals the cardiac septal defect occluder withdrawn within the sheath by the biopsy forceps. Given the ability for direct endoscopic visualization, no fluoroscopy is needed. The distal phalange is delivered on the remnant stomach side of the fistula and delivery system withdrawn slowly to ensure deployment of the proximal phalange is within the gastric pouch. As the system is withdrawn, mild resistance is felt as the distal phalange is compressed against the gastric remnant side of the fistula. Next, the pediatric forceps are slowly pushed out of the sheath to deliver the proximal phalange safely within the gastric pouch, effectively closing the gastrogastric fistula. It is important to not release the biopsy forceps too soon or early to ensure optimal position of the occluder device. The biopsy forceps are then opened to release the post on the occluder device. Here we can see the final appearance of the cardiac septal defect occluder within the fistula's tract. The distal phalange is compressing the remnant side and the proximal phalange compressing the pouch side, thereby closing the fistula's tract. Again, it remains critical to measure the diameter of the fistula accurately with the occluder being at least 50% larger than the orifice of the fistula. The procedure was uncomplicated and patient discharged the following day without issue. Follow-up barium swallow on post-op day 1 demonstrated no contrast within the remnant stomach, confirming successful gastrogastric fistula closure. At 1 month and 6 month follow-up, the patient's heartburn and postprandial symptoms had completely resolved. In this case, we successfully described the use of a cardiac septal defect occluder as a treatment for a chronic gastrogastric fistula in a Roux-en-Y gastric bypass patient. To summarize the steps to successful placement, first the occluder is back-loaded into the biliary catheter. Next, the pediatric forceps are placed down the biliary catheter and used to grasp the post on the open occluder. The forceps are then pulled back into the catheter and passed down the working channel of the gastroscope. Finally, once the system is in an appropriate position, the forceps are used to deploy the distal and proximal phalanges of the occluder across the fistula to effectively exclude the remnant stomach from the gastric pouch. There are two types of cardiac septal defect occluders, the ASD and VST device, each with specific sizes and waist diameters. Ultimately, it is very important that the diameter be at least 50% larger than the orifice of the fistula to ensure proper closure. Ultimately, this procedure was highly effective, able to be performed within 30 minutes, and did not require the use of fluoroscopy. Placement of a cardiac septal defect occluder may obviate the need for a laparoscopic or open surgical revision to achieve successful gastrogastric fistula closure. This may reduce further or future health care costs and improve patient quality of life. In conclusion, this video demonstrates that use of a cardiac septal defect occluder device is a feasible, highly effective, and safe technique for gastrogastric fistula closure. It is important to underscore this remains a non-FDA indicated use with future studies needed to validate these findings, compare outcomes to endoscopic and surgical treatment strategies, and perform cost-effectiveness analysis.

case study

gastro-gastric fistula

gastric bypass surgery

cardiac septal defect occluder device

endoscopic closure