Closure of an Iatrogenic Gastrogastric Fistula Created during an EDGE Procedure
Our patient is a 49-year-old woman with a history of Roux-en-Y gastric bypass who presented to an outside hospital with cholangitis. Because of her post-surgical anatomy, conventional ERCP was not feasible. After discussion of alternative drainage procedures, the outside hospital team elected to proceed with a novel EUS-directed transgastric ERCP, otherwise known as an EDGE procedure.
For reference, the EDGE procedure involves gaining access to the remnant stomach by creating a gastro- or jejunogastric fistula using a lumen-apposing metal stent, through which a duodenoscope can be passed and the biliary tree can be accessed in a more-or-less conventional manner.
So the outside hospital team proceeds with the EDGE procedure, and aresuccessful in creating a gastro-gastric fistula. ERCP is performed with successful removal of pus and sludge, and a plastic biliary stent is placed. On withdrawal of the duodenoscope, however, the lumen-apposing metal stent is accidentally dislodged. To salvage the gastro-gastric fistula, a fully covered esophageal stent is placed through it. This is anchored into place using a full thickness metal clip to attach the proximal end of the stent to the gastric pouch, then by placing four double pigtail stents through the esophageal stent. The patient’s cholangitis resolves, and she is discharged to rehab.
She presents to our institution several months later for further management. At this point, she has no further biliary symptoms, normal LFTs, and CT shows no choledocholithiasis or biliary dilatation, with the previously placed biliary stent in place. However, she has gained about 20 pounds since the initial procedure, and would like her bypass anatomyrestored.Therefore, after a multidisciplinary discussion with surgery, we plan to first repeat the ERCP, removing the indwelling biliary stent and clearing the duct of any remaining stones or sludge; to remove all indwelling stents from the gastrogastric fistula; and finally to close the gastrogastric fistula using endoscopic suturing, with plans for cholecystectomy shortly to follow.
Initial endoscopic and fluoroscopic views show the esophageal stent traversing the fistula, along with the pigtail stents and full thickness metal clip used to anchor it, the previously placed biliary stent, and dislodged lumen-apposing metal stent. Further inspection reveals the multiple double-pigtail stents used to anchor the esophageal stent. These are removed sequentially using a grasping forceps. The cleared esophageal stent, which traverses the gastrogastric fistula is visualized adjacent to the Roux limb. The scope is passed through the stent, into the remnant stomach. Just beyond the pylorus, the dislodged lumen-apposing metal stent is visualized and removed. The duodenoscope is then passed from the gastric pouch, through the gastrogastric fistula into the remnant stomach, and advanced to the second portion of the duodenum. The previously placed biliary stent is visualized in the ampulla, and a snare is used to remove the stent, with subsequent flow of bile and small stones. A cholangiogram is then performed showing numerous small filing defects. Multiple balloon sweeps are then performed to clear the bile duct of small stones and sludge, and a repeat cholangiogram shows an absence of filling defects.Following completion of ERCP, the esophageal stent is dislodged and removed.
Here we see the bare fistulous tract, to which APC is applied to denude the mucosa and enhance formation of granulation tissue, as well as promote healing once the tract is closed. The suturing device is then attached to the therapeutic gastroscope and advanced down a gastric-length overtube to the gastric pouch. A corkscrew-shaped tissue grasping device is used to draw mucosa into the path of the needle. The first stitch is thrown, and the needle and the suture are loaded back onto the needle driver. A second bite is taken. This process is repeated several more times until a running suture is complete, at which point the suture is cinched tight and an anchoring device is deployed to secure closure. Here we see the closed fistulous tract. A final single interrupted stitch is placed to oversew the tract and secure closure. We now see the tract oversewn. Final contrast injection shows no leakage into the remnant stomach. And finally, the various stents that were removed.
The patient underwent an uncomplicated cholecystectomy two weeks later and reports no further weight gain since the procedure. In conclusion, we show that weight regain is a potential untoward outcome of utilizing the EDGE procedure for biliary access post-gastric bypass; that closure of GI fistulae remains an important clinical challenge, one that may be overcome in certain situations through the application of endoscopic suturing, which is a versatile technique that can be utilized for clinically successful and durable fistula closure.