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ENDOSCOPIC CLOSURE OF GASTRO-GASTRIC FISTULA AFTER GASTRIC BYPASS: A TECHNICALLY FEASIBLE PROCEDURE BUT ASSOCIATED WITH LOW SUCCESS-RATE
Catherine Tsai*, Ulf Kessler, Rudolf Steffen, Hans Merki, Joerg Zehetner
Visceral Surgery, Clinic Beau Site, Bern, Bern, Switzerland

Background: Gastro-gastric fistulas are reported to be as high as 12% after gastric bypass for treatment of morbid obesity. While different endoscopic methods are described, the management traditionally consists of surgical revision with high associated morbidity. The aim of the study was to assess feasibility, safety and success-rate of endoscopic closure using an endoscopic suturing device.

Methods: From January 2016 to October 2017 we reviewed the electronic records of all patients undergoing endoscopic closure of a gastro-gastric fistula with the Apollo Overstitch system (Apollo Endosurgery, Austin, Texas, USA). Demographic details, procedure details and outcome variables were recorded.

Results: A total of 6 patients (M:F=5:1) underwent endoscopic fistula closure. Five patients (83.3%) had a prior banded gastric bypass (with subsequent band removal). The median number of prior abdominal surgeries was 3, the mean time after gastric bypass surgery was 5 years. While immediate complete endoscopic fistula closure was possible in 11 of 12 attempts in those 6 patients (92%), all patients had recurrent (persistent) fistulas at follow-up. After a mean follow-up time of 12 months 50% had further open (n=2) or laparoscopic (n=1) revision with complete fistula closure. Two patients are scheduled for laparoscopic revision, and one patient is refusing further intervention.

Conclusion: Endoscopic fistula closure with an endoscopic suturing device is feasible and safe. Unfortunately due to the nature of fistulas, permanent successful closure is rare. Therefore, the approach should be reserved for patients in whom a laparoscopic or open surgical attempt is impossible due to prior abdominal revisions.


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