Successful endoscopic closure of a gastrocutaneous fistula using a ‘Padlock Clip’
23 March 2016 (online)
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]).
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]).
Persistent iatrogenic gastrocutaneous fistulas are an uncommon, albeit well-recognized complication of PEG placement and removal . 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  . 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 .
To the best of our knowledge, this is only the second  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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