CLOSURE OF GASTROCUTANEOUS FISTULAS WITH AN OVER-THE-SCOPE-CLIP (OTSC) - A LARGE TERTIARY HOSPITAL EXPERIENCE

Introduction Gastrocutaneous fistulae (GF) are a rare, but difficult to manage complication after percutaneous endoscopic gastrostomy (PEG) tube removal. In cases, refractory to conventional medical management various approaches have been used for their treatment including; surgical closure, through the scope clipping and endoscopic suturing with variable results. The over-the-scope-clip (OTSC) has an emerging role in the endoscopic closure of gastrointestinal wall defects, including persistent GF. The aim of this study was to assess the efficacy and safety of the use of OTSC for the closure of persistent GF. Methods A prospectively kept database was analysedfrom September 2016 to January 2019 was undertaken of all persistent GF using an OTSC 12/6 GF clip. Prior to the deployment of an OTSC, the fistulous tract was disrupted using a wire brush, which also acted as a guide for placement. The use of ancillary techniques such as snare debulking or knife resection was utilised if needed. Primary outcome measures were; successful deployment of the OTSC, procedure time, complications and 30 day success. Secondary outcome measures were PEG dwell time prior to removal, time from diagnosis to closure and sedation type. Results A total of 22 procedures were performed, on 12 male & 10 female patients with a mean age of 47. Median PEG dwell time was 16 months prior to removal. 64% of the procedures were performed with conscious sedation, with 36% requiring enhanced sedation with anaesthetic support. Technical success was 100%, with 2 procedures requiring ancillary techniques to facilitate the deployment of the OTSC, resulting in 1 complication of intra-procedural bleeding (stopped endoscopically). The median procedure time was 14 mins (range 9–35). A 30 & 90 day success was reported in 96% cases, with only one fistula recurring. Discussion This is the largest cohort of patients with a persistent GF treated with an OTSC. This evolving procedure is an effective and safe method for the treatment of persistent GF. It has a much lower morbidity compared to surgery and shorter procedure times than more invasive endoscopic treatment options, such as endoscopic suturing.