Multimodal Endoscopic Therapy for Closure of a Gastrogastric Fistula: the “triple O” Method

Introduction: Surgical management of gastrointestinal (GI) fistulae is complex and evolving. Recently, numerous endoscopic tools and techniques have been introduced that have changed the management of these GI tract defects. However, each of these techniques has unique drawbacks that limit its applicability.1–4 One particularly challenging situation is the need for closure of a large defect within a small working space, such as a large gastrogastric fistula within a small gastric pouch. In this video, we present a novel method of multimodal endoscopic therapy, termed the “Triple O” closure technique.5 Materials and Methods: The patient was a 51-year-old female status post-Roux-en-Y gastric bypass who presented with chronic debilitating diarrhea. Workup, including a computed tomography scan and upper endoscopy, demonstrated a gastrogastric fistula. A multimodal endoscopic closure technique was employed. The method involves the placement of an over the scope clip (OTS-clip) over a suture closure performed using an Overstich endoscopic suturing device. The benefit of the “OTS-clip Over Overstitch,” or “Triple O” technique, is that it allows for reliable downsizing of the defect by placement of endoscopic sutures, followed by secondary closure utilizing an OTS-clip. This technique is particularly useful when working within the confines of a tight working space. In this video, we present a depiction of the use of this technique and demonstrate how the technique can be used as a rescue technique when endoscopic suturing alone fails to close a defect. Results: Complete closure of a gastrogastric fistula was achieved and confirmed with intraoperative fluoroscopy. The patient had resolution of her symptoms and no evidence of recurrence. Conclusion: Endoscopic closure of a large defect within a tight working space poses significant challenges. Multimodal closure methods prove useful in these circumstances. Importantly, this “Triple O” endoscopic closure method should be considered for closure of large defects within small working spaces, or in cases wherein endoscopic suturing is able to reduce the size of, but not fully close, an enteric defect. C.G.D., J.A.D., and V.V.A. have no competing financial interests. E.M.P.: Speaking/teaching: Cook Biotech, Inc., C.R. Bard, Inc., Boston Scientific Corp. Ovesco. Research Support: C.R. Bard, Inc. Consultant: Boston Scientific Corp., Actuated Medical, Inc., Medtronic, Baxter, Surgimatrix, CMR Surgical. Royalties: UpToDate, Inc., Springer. Runtime of video: 6 mins 54 secs This video was presented as a video presentation at the 2017 SAGES Annual Meeting in Houston, TX, USA, March 22, 2017.