Reopenable clip-over-the-line method for closure of postoperative gastric fistula

Nomura et al. developed the reopenable clip-over-the-line method (ROLM), originally reported for closure of large mucosal defects after endoscopic submucosal dissection (ESD) [1]. Its use has since expanded to managing perforations during ESD and suturing post–full-thickness resections [2] [3]. However, no reports have described its use for fistula closure. Common options such as the over-the-scope clip (OTSC) system (Ovesco Endoscopy GmbH) are often applied for fistula closure, but their success rate – especially in the gastric wall – is relatively low [4]. Endoscopic hand-suturing has also emerged as a closure method, though it remains technically complex [5].

We report the first case of successful gastric fistula closure using ROLM ([Video 1]). The patient was a 54-year-old woman who developed a postoperative pancreatic fistula (POPF) following distal pancreatectomy for pancreatic cancer ([Fig. 1] a). Despite drainage, the cavity progressively enlarged. On postoperative day (POD) 17, gastrography revealed a gastric fistula connected to the POPF ([Fig. 1] b). Conservative treatments including percutaneous drainage, total parenteral nutrition, and antibiotics failed to improve the condition.

Reopenable clip-over-the-line method for closure of postoperative gastric fistula.Video 1

Fig. 1 a Abdominal CT image reveals a defect in the gastric wall with leakage to the left subdiaphragmatic cavity (arrows). b Gastrography revealed the presence of a fistula (arrows). c The postoperative pancreatic fistula following a distal pancreatectomy for pancreatic cancer. d A clip with a line was first placed at the edge of the fistula. e A reopenable clip with a nylon line was applied to the contralateral edge of the fistula. f Pulling the nylon line approximated the two clips and achieved complete closure. g The fistula was completely closed 7 days after ROLM. h The complete closure of the fistula was confirmed by gastrography. Abbreviation: ROLM, reopenable clip-over-the-line method.

On POD 24, endoscopic closure was attempted. An initial attempt with the OTSC system was not pursued, as the rigidity of the surrounding gastric tissue suggested a high risk of failure. We then performed ROLM using a 3–0 monofilament nylon line and seven reopenable clips (SureClip 8 mm; MicroTech), achieving complete closure in 15 minutes ([Fig. 1] c–g). Fluoroscopy confirmed the absence of leakage into the abdominal cavity ([Fig. 1] h).

This case suggests that ROLM is not only effective for mucosal defects but also feasible for full-thickness gastric fistula closure. ROLM may offer a valuable and less complex alternative when conventional approaches are technically challenging.

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Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Nomura T, Sugimoto S, Temma T. et al. Clip-line closure with the reopenable clip over line method for a large mucosal defect after gastric endoscopic submucosal dissection. Endoscopy 2022; 54: E1-E2
• 2 Nomura T, Sugimoto S, Hisada H. et al. Closure of full-thickness perforation following endoscopic submucosal dissection of a gastric tumor near an anastomosis, using the reopenable clip-over-line method. Endoscopy 2023; 55 (S 01): E769-E770
• 3 Nomura T, Sugimoto S, Nakamura H. et al. Reopenable clip over line method for the closure of full-thickness defect after gastric endoscopic full-thickness resection. Endoscopy 2022; 54: E808-E809
• 4 Zhang J, Da B, Diao Y. et al. Efficacy and safety of over-the-scope clips (OTSC) for closure of gastrointestinal fistulas less than 2 cm. Surg Endosc 2022; 36: 5267-5274
• 5 Minoda Y, Fujimori N, Esaki M. et al. Rare complications related to lumen-apposing metal stent placement, successfully treated by endoscopic hand-suturing device. Endoscopy 2023; 55: E692-E693

Publication History

Article published online:
01 July 2025