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Background and Aims Fistulas after sleeve gastrectomy are major adverse events of bariatric surgery. The endoscopic management strategy evolved from closure to internal drainage after 2013. The main objective of our study was to evaluate and compare these different approaches. Methods This retrospective study included all patients treated for fistulas after sleeve gastrectomy in a referral center. Closure management was defined as initial treatment that used a covered metal stent and/or endoclips. Internal drainage management was defined as initial treatment by nasocystic drain and/or a double-pigtail stent. Results A total of 100 patients (women N = 78, mean [± standard deviation {SD}] age 42 ± 12 years) were included between 2007 and 2015. The mean (± SD) delay between sleeve gastrectomy and the first endoscopy was 82 ± 125 days. The overall success of endoscopic treatment was 86% within 6 ± 27 months. Two patients died. The primary success of internal drainage and closure management occurred in 19 of 22 (86%) and 49 of 77 (63%) patients, respectively. Among patients in failure for closure management, 22 had secondary internal drainage (18 being successful). Success of initial management was significantly higher for internal drainage ( P = .043). Factors associated with failure of closure management were in multivariable analysis: collection >5 cm ( P = .013). Factors associated with a time >6 months for achieving leakage closure were in multivariable analysis: reoperation before endoscopy ( P = .044) and purulent flow at endoscopy ( P = .043). Conclusions Endoscopic management of fistulas after sleeve gastrectomy was successful in 86% of cases. In cases of collections >5 cm, internal drainage should be proposed first. Surgical reintervention before endoscopy delays treatment success.

Background Endoscopy has evolved to become first-line therapy for the treatment of post-bariatric leaks; however, many sessions are often required with variable success rates. Due to these limitations, the use of the cardiac septal defect occluder (CSDO) has recently been reported in this population. Methods The study population was a multicenter retrospective series of patients with post-bariatric surgical leaks who underwent treatment with CSDO placement. Data on the type of surgery, previous treatment details, fistula dimensions, success rate, and adverse events were collected. Leaks were grouped according to the International Sleeve Gastrectomy Expert Panel Consensus. Outcomes included technical and clinical success and safety of the CSDO. Regression analysis was performed to determine the predictors of response. Results Forty-three patients with leaks were included (31 sleeve gastrectomy and 12 Roux-en-Y gastric bypass). They were divided into acute (n = 3), early (n = 5), late (n = 23), and chronic (n = 12). Forty patients had failed previous endoscopic treatment and 3 patients had CSDO as the primary treatment. Median follow-up was 34 weeks. Technical success was achieved in all patients and clinical success in 39 patients (90.7%). All chronic, late, and early leaks were successfully closed, except one undrained late leak. The 5 patients with early leaks had an initial satisfactory response, but within 30 days, drainage recurred. The CSDOs were removed and replaced with larger-diameter devices leading to permanent defect closure. Acute leaks were not successfully closed in all 3 patients. Regression analysis showed that chronicity and previous treatment were associated with fistula closure; success rates for late/chronic leaks versus acute/early leaks were 97.1% and 62.5%, respectively (P = .0023). Conclusion This observational study found that the CSDO had a high efficacy rate in patients with non-acute leaks, with no adverse events. All early, late, and chronic leaks were successfully closed, except for one undrained late leak. However, early leaks required a second placement of a larger CSDO in all cases. These results suggest that the CSDO should be considered for non-acute fistula and that traditional closure methods are likely preferred in the acute and early settings.

1. Brugge WR, Lewandrowski K, Lee-Lewandrowski E, et al. Diagnosis of pancreatic cystic neoplasms: a report of the cooperative pancreatic cyst study. Gastroenterology 2004;126:1330-6. 2. Raval JS, Zeh HJ, Moser AJ, et al. Pancreatic lymphoepithelial cysts express CEA and can contain mucous cells: potential pitfalls in the preoperative diagnosis. Mod Pathol 2010;23:1467-76. 3. Morris-Stiff G, Lentz G, Chalikonda S, et al. Pancreatic cyst aspiration analysis for cystic neoplasms: mucin or carcinoembryonic antigen--which is

Background Gastrogastric fistulas (GGFs) are seen in 1.5% to 12.5% of patients after Roux-en-Y gastric bypass (RYGB) bariatric surgery, often leading to failure to lose adequate weight. Objective The aim of this study was to assess the feasibility, safety, and percentage of successful primary endoluminal closures of GGFs by using a recently developed tissue apposition system in combination with local mucosectomy. Design A feasibility and outcome study following institutional review board protocol. Setting Tertiary referral teaching hospital, Legacy Health System, Portland, Oregon. Interventions A combination of mucosectomy and nonresorbable tissue apposition is used to achieve a permanent closure of the GGF. Patients Four patients with 5 GGFs after RYGB; the mean fistula diameter of was 18.6 mm (range 10-30 mm). Results Primary closure rate (1 endoscopic session) of 5 GGFs was 100%. The mean procedure time was 88.5 minutes. One to 4 pairs of tissue anchors were used to close the fistulas. The mean time for performing mucosectomy was 21.6 minutes (range 8-42 minutes) and 39.6 minutes (range 12-58 minutes) for fistula closure. Estimated blood loss was on average 2 mL (range 0-5 mL). No complications were recorded. Early success (3 months), as evidenced by early satiety and weight loss, was noted for 3 of 4 patients. After 3 months, only the smallest fistula (10 mm) was still completely closed, and after 6 months, it also showed a pinhole opening. Conclusion It was feasible to close all fistulas endoscopically without complications. Permanent closure of GGFs could not be achieved.

Background Development of persistent gastrocutaneous fistula and leakage after the removal of a PEG tube is a well-known complication. Various treatments including medications to alter gastric pH, prokinetic agents, endoscopic clipping/suturing, electric and chemical cauterization, argon plasma coagulation, and fibrin sealant, have been used with variable success. Although surgical closure is the current treatment of choice, most of the elderly patients are poor surgical candidates because of multiple comorbid conditions. Objective We describe a method of endoscopic suturing of a gastrocutaneous fistula that is a safe and cost-effective alternative to surgical closure. Design Individual case. Setting Community hospital. Patient One elderly patient. Interventions By using a trocar, we placed multiple, long monofilament sutures from the skin around the gastrocutaneous fistula in criss-cross fashion. Gastric ends of these sutures were pulled from the stomach with a snare under endoscopic visualization. Suture knots were made at the gastric end of the sutures and then were pulled back from the cutaneous side. Multiple biopsy specimens were obtained from both ends of the fistula to promote granulation tissue. Final knots were made at skin level to obliterate the fistula. Result Our procedure resulted in complete closure of a large, persistently leaking gastrocutaneous fistula in an elderly patient within 7 days. The patient tolerated the optimal rate of enteral nutrition without further leakage. Limitation Only 1 patient. Conclusion We believe that this method of endoscopic suturing along with de-epithelialization of the fistula tract for persistent gastrocutaneous fistula is a safe and cost-effective alternative to surgical closure.

Background Chronic gastrocutaneous fistula with intermittent drainage is a common outcome after removing long-standing gastrostomy tubes. The standard treatment is surgery with laparotomy and excision of the fistula tract. This study describes the results of an endoscopic closure technique by using a combination of electrocautery and metal clips. Methods Three patients with gastrocutaneous fistulas (duration 3 months to 3 years) after gastrostomy tube removal were treated endoscopically by electrocautery of the tract and application of metal clips. Observations Treatment resulted in complete fistula closure in two patients and partial closure in a third patient. Conclusions Combined endoscopic therapy with electrocautery and clipping may be an alternative to surgical closure of chronic gastrocutaneous fistulas.

Background Gastrocutaneous fistula is an uncommon and difficult to treat complication that occurs in 0.5% to 3.9% of patients who undergo gastric surgery. Sepsis usually follows, and, when it is not managed effectively, the associated mortality rate can be as high as 85%. A fibrin sealant was used to endoscopically manage gastrocutaneous fistulas that developed in 3 morbidly obese patients after bariatric surgery. Methods Two of 14 (14.29%) patients who underwent vertical gastroplasty (MacLean procedure) developed a non-healing gastrocutaneous fistula. In addition, one of 24 (4.17%) patients who had a biliopancreatic diversion with preservation of pylorus developed a gastrocutaneous fistula. Endoscopic application of a fibrin sealant was performed under direct vision via a double-lumen catheter passed through a forward-viewing endoscope. Observations Treatment was successful in all patients after one or more endoscopic sessions in which the fibrin sealant was applied; no evidence of fistula was found at follow-up endoscopy. Conclusions Endoscopic closure of gastrocutaneous fistula with human fibrin tissue sealant is simple, safe, and effective, and, in some cases, can be life-saving. Endoscopic application of fibrin sealant should be considered a therapeutic option for treatment of gastrocutaneous fistula that develops after bariatric surgery.

Background Aorto-enteric fistula is rare but can result in exsanguination without timely surgery or endovascular stent placement. Methods Four cases of aorto-enteric fistula were reviewed in which the presentation was unusual and diagnosis difficult. Observations The first patient had an aorto-sigmoid fistula in the setting of an aorto-bi-femoral graft. Two patients had a primary aorto-enteric fistula, one to the stomach from a suprarenal aortic aneurysm, and the other, to the duodenum in the setting of retroperitoneal spread of renal cancer. The aortoduodenal fistula recurred in the 4th patient within 3 months of surgical repair; this patient is the only one who survived long term. Conclusions When presentation is atypical, the diagnosis of aorto-enteric fistula can be extremely difficult. Because investigative studies are not consistently useful in making a definitive pre-operative diagnosis, a strong index of clinical suspicion and a willingness to consider surgical exploration are essential for timely and successful management.

The perceived health benefits of enteral feeding have placed increasing demands on endoscopists to acquire the expertise needed to establish enteral access, to monitor patients undergoing enteral feeding, and to manage the complications arising from the initial access procedure. In the setting of acute critical care, the provision of enteral feeding is seen as therapy that reduces systemic bacterial challenge to the host, attenuates the stress response, downregulates both innate and acquired immune responses, and improves outcomes for the patient. 1 In long-term chronic care, achieving enteral access may serve to decrease the risk of aspiration by diverting the feeding stream to more distal segments of the GI tract, 2 to reduce the morbidity that accompanies protein-calorie malnutrition, to provide an effective bridge for patients expected to regain neurologic function, and to facilitate efficient supportive management and utilization of health care resources. Complications are inherent to the moderately invasive endoscopic procedures for achieving enteral access. Older age and the existence of comorbid conditions increase this risk. Proper patient selection and appropriate modification of endoscopic technique to suit the peculiarities to the individual case may decrease risk during initial tube placement. Proper monitoring, early recognition of impending complications, and quick, often simple, endoscopic solutions can reduce the frequency and the severity of enteral access‐associated complications.

Background Endoscopic clipping for closing a fistula created by surgery is often difficult because of the combination of a wide orifice and fibrosis. Creating holes for prongs of a clip may constitute a new endoscopic clipping technique for closing the wide orifice of a fistula. Objective To assess the feasibility of performing the endoscopic hole and clipping technique (EHCT). Design Experimental pilot study. Setting Tertiary-care referral center. Patient This study involved 1 patient who underwent EHCT. Interventions EHCT was performed. Main Outcome Measurements Technical success and procedural complications of EHCT. Results Immediately after the procedure, drainage decreased dramatically and finally decreased to 0 mL/d. There was no evidence of a leak on fluoroscopic examination, and upon 4-month follow-up, we found that no symptoms had developed in the patient. Limitations Single-patient pilot study. Conclusions EHCT is very simple and efficient. EHCT can be applied as a means of closing the orifice of a postoperative fistula that is not easily managed by simple endoscopic clipping.

y t w f O c p t Through-the-scope (TTS) clipping devices have been available for nearly 20 years, and applications include the treatment of GI bleeding, closure of perforations and fistulae, and anchoring of feeding tubes. Although these evices are relatively inexpensive and easy to use, they ave limited opening widths and closing strengths and are sually ineffective in the setting of fibrotic tissue. Recently, publications emerged demonstrating the feaibility and use of a novel over-the-scope clip (OTSC) evice.5 Experimental studies have demonstrated the abilty of the OTSC to close perforations6-8 and control arterial leeding.9 Comparative animal trials have shown the sueriority of OTSCs relative to TTS clips for closure of erforations10,11 and natural orifice transluminal endoscopic surgery (NOTES) access points.12-14 Subsequent case reports and small case series in humans have shown great promise of the device for the treatment of arterial bleeding and for the closure of endoscopic perforations and fistulae.15,16 The largest series published to date comrises 50 patients.17 All of these studies have emanated

Background The over-the-scope clip (OTSC) system was first used to close the access route in natural orifice transluminal endoscopic surgery and is increasingly used for other indications. Objective We analyzed the use of the OTSC in intestinal bleeding and in closure of GI tract leaks. Design Analysis of a consecutive series of patients. Setting University hospital. Patients Nineteen patients (group A: closure of GI leak site, n=12; group B: complex GI bleeding, n=7) were retrospectively enrolled in this study. We analyzed outcome and follow-up (6-68 weeks; group A: mean 37 weeks, standard deviation 24) in terms of treatment success (closure of the GI tract leak/durable hemostasis). Intervention Endoscopic application of OTSCs. Main Outcome Measurements Resolution of leaks, closure of fistula (group A), or stopping bleeding (group B). Results In group A, durable closure was achieved in 8 of 12 patients. Sealing a postoperative/postinterventional leak was successful in 6 patients and failed in 3. A gastrocutaneous fistula was primarily closed successfully in 2 patients, but recurred in 1 of these patients. A gastric wall dehiscence in necrotizing pancreatitis was successfully closed in another patient. Group B patients had previous endoscopic treatment failure in 4 of 7 patients (through-the-scope clips, injection of Suprarenin or fibrin glue, others) and were deemed not treatable by through-the-scope clips in 3 of 7 patients. The primary success rate was 100% (7 of 7 patients); durable hemostasis was achieved in 4 of 7 patients, whereas surgery or angiography was necessary in the remaining patients. Limitations Retrospective analysis. Conclusions Leaks and fistulae are reliably closed with OTSCs in tissue flexible enough to be sucked into the attached cap (eg, in lesions caused

Gastrocolic fistula is an abnormal communication between a segment of the colon and the stomach. It can be caused by both benign and malignant conditions. 1-4 The patient is usually seen with weight loss, feculent vomiting, and diarrhea. Surgical treatment is often required for definitive management of this condition, although several endoscopic techniques have been reported. 5,6 Gastrocolic fistula is very rarely caused by gastric cancer because it is usually diagnosed earlier. We present a case of successful palliation of gastrocolic fistula secondary to gastric cancer by insertion of a covered colonic stent.

Background Gastrocolonic fistula after percutaneous endoscopic gastrostomy PEG tube placement is an uncommon but serious complication. These fistulous tracts are often fibrotic and frequently require surgical intervention. Objective To describe a novel endoscopic treatment for gastrocolonic fistula. Design Case report. Setting Inpatient hospital setting. Patient An 82-year-old woman was seen 1 year after PEG placement with feculent vomiting; imaging studies showed a gastrocolonic fistula. Cardiopulmonary comorbidities posed an unacceptable surgical risk. Endoscopic attempts at fistula closure with hemoclip placement and biodegradable plug were unsuccessful. Total parenteral nutrition resulted in multiple metabolic and infectious complications. Intervention Gastrocolonic fistula closure was performed twice by using cardiac septal defect closure devices. The first closure was achieved by using the Amplatzer double-disk nitinol wire mesh atrial septal defect closure device, which was deployed under endoscopic and fluoroscopic guidance across the fistula tract. The proximal disk was then injected with cyanoacrylate glue to create a watertight seal. The second closure, performed 4 months later after collapse of the initial device, was performed by using the CardioSEAL septal repair implant. This was secured in place with hemoclips and similarly injected with cyanoacrylate glue to create a watertight seal. Main Outcome Measurements Fistula closure, as determined by contrast gastrogram through a PEG tube and gastrograffin enema. Results Successful fistula closure was achieved for 4 months after initial device placement. After the second device was placed, the patient remained clinically well until her demise 18 months later from unrelated causes. Limitations These procedures were performed on only one subject. Conclusions Successful endoscopic closure of gastrocolonic fistula can be achieved, even with long-standing, fibrotic fistulous tracts by using a novel endoscopic approach.

Background The endoscopic full-thickness Plicator device was initially developed to provide an endoscopic treatment option for patients with GERD. Because the endoscopic full-thickness Plicator enables rapid and easy placement of transmural sutures, comparable with surgical sutures, we used the Plicator device for endoscopic treatment or prevention of GI-wall defects. Objective To describe the outcomes and complications of endoscopic full-thickness suturing during EMR and for the treatment of gastric-wall defects. Design A report of 4 cases treated with the endoscopic full-thickness suturing between June 2006 and April 2007. Setting A large tertiary-referral center. Patients Four subjects received endoscopic full-thickness suturing. The subjects were women, with a mean age of 67 years. Interventions Of the 4 subjects, 3 received endoscopic full-thickness suturing during or after an EMR. One subject received endoscopic full-thickness suturing for treatment of a fistula. Main Outcome Measurements Primary outcome measurements were clinical procedural success and procedure-related adverse events. Results The mean time for endoscopic full-thickness suturing was 15 minutes. In all cases, GI-wall patency was restored or ensured, and no procedure-related complications occurred. All subjects responded well to endoscopic full-thickness suturing. Limitations The resection of one GI stromal tumor was incomplete. Because of the Plicator's 60F distal-end diameter, endoscopic full-thickness suturing could only be performed with the patient under midazolam and propofol sedation. The durable Plicator suture might compromise the endoscopic follow-up after EMR. Conclusions The endoscopic full-thickness Plicator permits rapid and easy placement of transmural sutures and seems to be a safe and effective alternative to surgical intervention to restore GI-wall defects or to ensure GI-wall patency during EMR procedures.