Endoscopic closure of gastrogastric fistulas by using a tissue apposition system (with videos)

Background

Gastrogastric fistulas (GGFs) are seen in 1.5% to 12.5% of patients after Roux-en-Y gastric bypass (RYGB) bariatric surgery, often leading to failure to lose adequate weight.

Objective

The aim of this study was to assess the feasibility, safety, and percentage of successful primary endoluminal closures of GGFs by using a recently developed tissue apposition system in combination with local mucosectomy.

Design

A feasibility and outcome study following institutional review board protocol.

Setting

Tertiary referral teaching hospital, Legacy Health System, Portland, Oregon.

Interventions

A combination of mucosectomy and nonresorbable tissue apposition is used to achieve a permanent closure of the GGF.

Patients

Four patients with 5 GGFs after RYGB; the mean fistula diameter of was 18.6 mm (range 10-30 mm).

Results

Primary closure rate (1 endoscopic session) of 5 GGFs was 100%. The mean procedure time was 88.5 minutes. One to 4 pairs of tissue anchors were used to close the fistulas. The mean time for performing mucosectomy was 21.6 minutes (range 8-42 minutes) and 39.6 minutes (range 12-58 minutes) for fistula closure. Estimated blood loss was on average 2 mL (range 0-5 mL). No complications were recorded. Early success (3 months), as evidenced by early satiety and weight loss, was noted for 3 of 4 patients. After 3 months, only the smallest fistula (10 mm) was still completely closed, and after 6 months, it also showed a pinhole opening.

Conclusion

It was feasible to close all fistulas endoscopically without complications. Permanent closure of GGFs could not be achieved.

Abbreviations: GGF, gastrogastric fistula, RYGB, Roux-en-Y gastric bypass, TAS, tissue apposition system