Endoscopic Management of Chronic Gastrocutaneous Fistula after Revisional Bariatric Surgery Using Multiple Simultaneous Endoscopic Techniques: A Case Report

Introduction Gastrocutaneous fistula (GCF) is a rare but difficult-to-manage complication, which occurs in up to 5.1% in sleeve gastrectomy. Management is usually multimodal and can include surgery, endoscopy, and interventional radiology.

Case Report A 55-year-old male presented to our center for persistent non-healing and draining GCF. He had undergone his first bariatric surgery as a Roux-and-Y gastric bypass 15 years prior. This was later revised to a sleeve gastrectomy due to metabolic complications. A gastro-gastric anastomotic leak had matured into a GCF, which had been persistently draining for more than 3 years. At the time of presentation to our center, a surgical drain was in place managing a high output fistula. Upper endoscopy revealed drain erosion into the gastric lumen. The drain was removed, and the fistula tract was debrided with an endoscopic brush. A triangular tip electrosurgical knife was used to cauterize fistula edges, and then a 10-mm Over-The-Scope-Clip (OTSC) was applied. To aid in gastric emptying, 100 units of botulinum toxin were injected into the pylorus, and a small-caliber nasojejunal feeding tube was placed for nutritional supplementation. A repeat endoscopy performed 3 weeks later demonstrated a healed fistula, and the patient was advanced to per oral diet.

Learning Points This case report demonstrates successful endoscopic closure of a chronic GCF using several endoscopic techniques in a single endoscopy session. In this case, endoscopy spared surgical re-intervention with its attendant risk of morbidity.