Successful endoscopic closure of a gastrocutaneous fistula using a ‘Padlock Clip’

A 27-year-old woman with severe neurological disability and portal hypertension secondary to Wilson’s disease was referred for endoscopic closure of a chronic gastrocutaneous fistula following the removal of a percutaneous endoscopic gastrostomy (PEG) tube 8 months previously ([Fig. 1]). The patient suffered from skin denudation caused by leakage of gastric secretions. At upper gastrointestinal endoscopy, the gastric side of the fistula was identified on the anterior wall of the stomach ([Fig. 2]).

Fig. 1 Gastrocutaneous fistula (black arrow), cutaneous side. The external appearance shows associated chemical excoriation of the skin by leakage of gastric contents.

Fig. 2 Gastrocutaneous fistula (black arrow), gastric side, endoscopic view.

Using a circular Padlock Clip and its dedicated Lock-It delivery system (Aponos Medical Corp., Kingston, New Hampshire, USA) mounted onto a gastroscope ([Fig. 3]), the gastric side fistula margins ([Fig. 4 a]) were drawn into the plastic tissue chamber of the device by endoscopic suction. The Padlock Clip was then deployed once the margins were completely within the tissue chamber, successfully closing the fistula in a circular fashion ([Fig. 4 b], [Video 1]). After the procedure, cross-sectional imaging confirmed successful closure of the fistula without leakage of luminal contrast ([Fig. 5]).

Fig. 3 Padlock Clip seen mounted onto a gastroscope alongside its dedicated Lock-It delivery system (Aponos Medical Corp., Kingston, New Hampshire, USA).

Fig. 4 Endoscopic view of clip (black arrow) deployment for closure of the gastrocutaneous fistula (white arrow). a The fistula before being drawn into the plastic tissue chamber of the clip delivery system by endoscopic suction. b After deployment of the Padlock Clip (Aponos Medical Corp., Kingston, New Hampshire, USA).

Gastrocutaneous fistula closure using an endoscopically deployed Padlock Clip (Aponos Medical Corp., Kingston, New Hampshire, USA).

Fig. 5 Sagittal computed tomographic scan images. a Before closure of the gastrocutaneous fistula (white arrow). b 12 months after closure using the Padlock Clip (Aponos Medical Corp., Kingston, New Hampshire, USA) (white arrow).

Persistent iatrogenic gastrocutaneous fistulas are an uncommon, albeit well-recognized complication of PEG placement and removal [1]. In recent years, a “bear-claw” type, over-the-scope-clip system (OTSC; Ovesco AG, Tübingen, Germany) has been shown to be safe and effective for linear closure of a variety of fistulae and perforations [2] [3]. The newly developed Padlock Clip, although based on a very similar principle to that of the OTSC, uses a circumferential 6-pronged design for radial compression of tissue to effectively and safely close a defect in a similar fashion to a purse-string suturing technique [4].

To the best of our knowledge, this is only the second [5] clinical description of effective closure of a PEG-related persistent gastrocutaneous fistula using a Padlock Clip. In selected cases, the Padlock Clip may represent another endoscopic, minimally invasive and cost-effective alternative to surgery for closure of tissue defects and fistulas within the gastrointestinal tract.

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• References

• 1 Hameed H, Kalim S, Khan YI. Closure of a nonhealing gastrocutanous fistula using argon plasma coagulation and endoscopic hemoclips. Can J Gastroenterol 2009; 23: 217-219
• 2 Parodi A, Repici A, Pedroni A et al. Endoscopic management of GI perforations with a new over-the scope clip device (with video). Gastrointest Endosc 2010; 72: 881-886
• 3 Mönkemüller K, Sarker S, Baig KR. Endoscopic creation of an omental patch with an over-the-scope clip system after endoscopic excavation and resection of a large gastrointestinal stromal tumor of the stomach. Endoscopy 2014; 46 (Suppl. 01) E451-E452
• 4 Desilets DJ, Romanelli JR, Earle DB et al. Gastrotomy closure with the lock-it system and the Padlock-G clip: a survival study in a porcine model. Laparoendosc Adv Surg Tech A 2010; 20: 671-676
• 5 Abraham A, Vasant DH, McLaughlin J et al. Endoscopic closure of a refractory gastrocutaneous fistula using a novel over-the-scope Padlock clip following de-epithelialisation of the fistula tract. BMJ 2015; DOI: 10.1136/bcr-2015-211242.