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Introduction and Aims: PEG removal in head and neck cancer patients (HNCPs) is performed after treatment, in case of disease remission and after adequate oral intake is resumed. The PEG tract usually closes spontaneously within 2-3 days. Persistent gastrocutaneous fistula (GCF) is a rare complication after PEG tube removal and is characterized by the persistence of gastric leakage through the fistulous tract for more than 1 month. Our main goal was to access the incidence and the success of a treatment algorithm for GCF in HNCPs., Methods: Retrospective unicentric study of HNCPs referred for PEG removal between 2014 and 2018. The patients with GCF were selected and their sequential treatment was reviewed., Results: In 331 patients with PEGs removed, 19 (5.7%) GCFs were documented. Medical therapy (4-8 weeks) was performed with clinical success (definitive closure of the GCF) in 12 (63.2%) patients. The remaining seven patients required endoscopic or surgical treatment. In four, endoscopic treatment had technical and clinical success (in three patients with fulguration of the gastric leak edges with argon plasma coagulation, silver nitrate in the path and external orifice, and closure of the internal orifice with hemoclips and in one with an over-the-scope-clip). Only three patients underwent surgery, one due to clinical failure of sequential endoscopic therapy and two had direct surgery., Conclusion: GCF occurs rarely after PEG removal in HNCPs. Medical therapy is usually effective and should be maintained for at least 8 weeks. Endoscopic therapy is an effective second-line option with and surgery rarely required.

Background: The management for subacute or chronic fistula after bariatric surgery is very complicated and with no standard protocol yet. It is also an Achilles' heel of all bariatric surgery. The aim of this case report is to describe our experience in managing this complication by percutaneous embolization, a less commonly used method., Case Presentation: A 23-year-old woman with a body mass index of 35.7 kg/m 2 presented with delayed gastric leak 7 days after laparoscopic sleeve gastrectomy (LSG) for weight reduction. Persistent leak was still noted under the status of nil per os, nasogastric decompression, and parenteral nutrition for 1 month; therefore, endoscopic glue injection was performed. The fistula tract did not seal off, and the size of pseudocavity enlarged after gas inflation during endoscopic intervention. Subsequently, we successfully managed this subacute gastric fistula via percutaneous fistula tract embolization (PFTE) with removal of the external drain 2 months after LSG., Conclusions: PFTE can serve as one of the non-invasive methods to treat subacute gastric fistula after LSG. The usage of fluoroscopy-visible glue for embolization can seal the fistula tract precisely and avoid the negative impact from gas inflation during endoscopic intervention.

A gastrogastric fistula is a rare complication of Roux-en-Y gastric bypass resulting from communication between the gastric pouch and gastric remnant. This case report describes the creative interprofessional management of this condition arising in a 48-year-old woman. During an elective Roux-en-Y gastric bypass surgery for morbid obesity, the patient developed respiratory complications. She was admitted to the ICU, but the following day she signed herself out against medical advice, stating she was "no longer staying here." Within 24 hours, she returned to the ED for postoperative complications, and a week after the exploratory surgery, the patient developed an inoperable high-output fistula. The authors devised a creative solution to contain the effluent and achieved closure of the fistula after several weeks.

Background: Thoracogastric airway fistula (TGAF) is a serious complication of esophagectomy for esophageal cancer. We conducted a systematic review of the appropriate therapeutic options for acquired TGAF., Methods: We performed a literature search to identify relevant studies from PubMed, EMBASE, and Web of Science using the search terms "gastric airway fistula", "gastrotracheal fistula", "gastrobronchial fistula", "tracheogastric fistula", "bronchogastric fistula", "esophageal cancer", and "esophagectomy"., Result: Twenty-four studies (89 patients) were selected for analysis. Cough was the main clinical presentation of TGAF. The main bronchus was the most common place for fistulas (53/89), and 29 fistulas occurred in the trachea. Almost 73% (65/89) of patients underwent non-surgical treatment of whom 87.7% (57/65) received initial fistula closure. Twenty-three patients underwent surgery, including 19 (82.6%) with initial closure. The 1-, 2-, 3-, 6-, and 9-month survival rates in patients who underwent surgical repair were 95.65%, 95.65%, 82.61%, 72.73%, and 38.10%, respectively, and the equivalent survival rates in patients with tracheal stent placement were 91.67%, 86.67%, 71.67%, 36.96%, and 13.33%, respectively., Conclusion: TGAF should be suspected in patients with persistent cough, especially in a recumbent position or associated with food intake. Individualized treatment should be emphasized based on the general condition of each patient.

Background: There is no time limit for the occurrence of leaks after sleeve gastrectomy LSG, and very late ones might evolve versus persistent, chronic fistulas. The aim of this retrospective study was to analyze the incidence, treatment and outcomes of persistent, chronic fistulas occurred or treated in a bariatric Center of Excellence IFSO-EC (CoE) and to establish a standardized approach. Materials Methods: between 2011-2018, nine cases of postoperative leaks occurred on a total of 1365 LSG performed (0.65%), 7 of them having late presentations (onset over 10 days postoperative). Chronic, persistent fistulas were identified and analyzed, including one gastro-bronchial and one gastro-cutaneous fistulas. Results: We present three peculiar cases of very late, chronic type III fistulas, with onset at 6-84 months after primary LSG and their management, including conservative, interventional radiology and endoscopy and surgical therapies. Conclusions: the management of late, chronic type III fistula is variable, with no standard algorithm to follow, but it should be planned based on the clinical evaluation, time of diagnosis, available resources, multidisciplinary approach and expertise. This emphasises again the necessity of a bariatric CoE that can guarantee a better diagnose and treatment, based on the use of wide, available resources, both professional and material., (Celsius.)

Background: Leaks are rare complications of laparoscopic sleeve gastrectomy (LSG) but, they may cause significant and prolonged morbidity. Enteral nutrition is mandatory for the gastric leak or fistula therapy's success and the naso-jejunal tube (NJT) as well the loop feeding jejunostomy (LFJ) have some limitations and morbidities. We propose an alternative, the laparoscopic Roux-en-Y feeding jejunostomy (LRYFJ) to support the mid- and long-term nutritional need of the patients complicated with gastric leaks or fistulas. Aim: to investigate the laparoscopic Roux-en-Y feeding jejunostomy (LRFJ) and to evaluate the surgical technique, its efficiency and outcomes. Methods: The surgical steps of LRFJ are described in detail and the technical challenges are commented. The IRB approval was obtained for performing the LRYFJ in patients with gastric leaks or fistulas after LSG and to run the present study. All the patients who received LRYFJ in our center since 2015 were included into a prospective study. The patient's medical characteristics, as well the procedure's technical challenges and outcomes are analyzed. Result: Six patients (4 females, 2 males; age 37.1 +- 11.5 years) who previously underwent LSG, were referred to our unit after the initial drainage for gastric leak in other institution and, LRYFJ was performed in all. Mean operative time was 127.5 +- 61.2 minutes. Mean duration of jejunal nutrition was 183.83 +- 128.2 days. No related mortality was encountered. Laparoscopic fistulo-jejunostomy was the definitive fistula treatment in five of the patients (83.3 %) while in one patient (16.6 %) the leak was spontaneously healed. Conclusion: Adequate nutritional support is mandatory for the gastric sleeve leak treatment. LRYFJ has many advantages over naso-jejunal tube and loop type feeding jejunostomy particularly in treatments of prolonged sleeve leaks or fistulas. Our experience demonstrates that LRYFJ can be implemented safely with the technique we described., (Celsius.)

A gastrointestinal-airway fistula (GAF) after esophagectomy is a very serious postoperative complication that can cause severe respiratory complications due to digestive juice inflow. Generally, GAF is managed by invasive surgical treatment; less-invasive treatment has yet to be established. We performed esophageal stent placement (ESP) in three cases of GAF after esophagectomy. We assessed the usefulness of ESP through our clinical experience. All GAFs were successfully managed by ESP procedures. After the procedure, the stent positioning and expansion were appropriately evaluated by radiological assessments over time. The stent was removed after endoscopic confirmation of fistula closure on days 8, 23, and 71. Only one patient with a long-term indwelling stent developed a manageable secondary gastrobronchial fistula as a procedure-related complication. In conclusion, ESP was shown to be a less-invasive and effective therapeutic modality for the treatment of GAF.

We describe a patient who developed an intractable leak from the gastric sleeve after laparoscopic sleeve gastrectomy, resulting in the development of a gastrobronchial fistula. Affected individuals typically have a persistent leak from the gastric sleeve with recurrent subphrenic abscesses, and when a gastrobronchial fistula develops, these patients may present with paroxysms of coughing immediately after ingestion of solids or liquids. In the appropriate clinical setting, a barium study not only may show the leak, but also directly visualize the gastrobronchial fistula. If aggressive endoscopic dilation procedures and/or endoscopic placement of stents or clips fail to facilitate healing of the leak and fistula, these patients may require surgical intervention, with conversion of the sleeve to a Roux-en-Y gastric bypass or even a partial or total gastrectomy. The development of a gastrobronchial fistula after sleeve gastrectomy therefore can be extremely challenging to manage., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Background: Thoracogastric-airway fistula (TGAF) post-thoracic surgery is a rare and challenging complication for esophagectomy. The aim of this study was to explore the effectiveness of airway stenting for TGAF patients and find related factors coupled with healing of fistula., Methods: This is a retrospective study involving patients with TGAF who were treated with airway stentings. Based on different TGAF locations and sizes on chest computed tomography, covered metallic or silicon airway stents were implanted to cover orifices under interventional bronchoscopy. TGAF healing was defined as the primary outcome, and complete sealing of TGAF as the second outcome. The predictors for TGAF healing were analyzed in univariate and multivariate analysis., Results: A total of 58 TGAF patients were included, of whom 7 received straight covered metallic stents, 5 straight silicon stents, 3 L-shaped covered metallic stents, 21 large Y-shaped covered metallic stents, 17 large Y-shaped silicon stents, and 5 with Y-shaped covered metallic stents. Healing was achieved in 20 (34.5%) patients, and complete sealing in 45 (77.6%) patients. There were no significant differences in healing rate and complete sealing rate between patients receiving metallic stents and those with silicon stents. In univariate analysis, lacking a previous history of radiotherapy or chemotherapy, nonmalignant fistulas, small fistulas, and shorter postesophagectomy duration were found associated with a higher rate of TGAF healing. Only shorter postesophagectomy duration was associated with TGAF healing in multivariate analysis., Conclusions: Both silicon and covered metallic airway stenting are effective methods to close TGAF. A shorter postesophagectomy period may predict better TGAF healing. The reviews of this paper are available via the supplemental material section.

Hemorrhagic complications are the most common major complications that occur after radiofrequency ablation, but hematemesis as a complication after radiofrequency ablation for hepatic tumor has not been mentioned before. A hepatogastric fistula as a delayed complication is also rare. We present the case of a 77-year-old man with severe hematemesis that occurred 2 months after radiofrequency ablation of a liver metastasis of gastric cancer. A ruptured hepatic artery pseudoaneurysm and a hepatogastric fistula were confirmed through serial imaging examinations. The current case is reported in combination with 2 rare major complications after radiofrequency ablation of a liver tumor., (Copyright © 2018. Published by Elsevier Inc.)

Background: Gastrostomy tubes are a common adjunct to the care of vulnerable pediatric patients. This study systematically evaluates the epidemiology and risk-factors for gastrocutaneous fistulae (GCF) after gastrostomy removal in children and reviews treatment options focusing on nonoperative management (NOM)., Methods: After protocol registration (CRD-42017059565), multiple databases were searched. Studies describing epidemiology in children and GCF treatment at any age were included. Critical appraisal was performed (MINORS risk-of-bias assessment tool). One-sided meta-analysis was executed to estimate efficacy of therapeutic adjuncts using a random-effects model., Results: Sixteen articles evaluating pediatric GCF were identified. 44% defined GCF as persistence >1month which occurred in 31±7% of cases. Risk factors for pediatric GCF include age at gastrostomy, timing of removal, open technique, and fundoplication. Mean MINORS score was 0.60±0.16. Seventeen additional studies were identified reporting 142 patients undergoing NOM (endoscopic, systemic, and local therapies), and one pediatric comparative study was identified. Overall aggregate proportion of GCF closure after any NOM is 77% (80% success rate in local/systemic therapies; 75% success rate in endoscopic approaches). No adverse events were reported., Conclusion: Persistent GCF complicates the management of gastrostomies in 1/3 of children with predictable risk factors. Several treatment options exist that obviate the need for general anesthesia. Their efficacy is unclear. Further prospective investigations are clearly warranted., Level of Evidence: III - Systematic Review and Meta-Analysis Based on Retrospective Case Control Studies., (Copyright © 2018. Published by Elsevier Inc.)

Rationale: Aortogastric fistula (AGF) is a rare but devastating clinical complication after esophagectomy. In a recent report, nearly all AGF patients died of massive hemorrhage or aspiration of massive hematemesis. Therefore, timely appropriate treatment of AGF remains a challenge.Herein, we report a case of AGF that resulted from peptic ulceration after esophagectomy and was successfully treated with endovascular stent graft placement., Patient Concerns: A 59-year-old man had undergone video-assisted thoracoscopic esophagectomy for squamous cell carcinoma and esophageal reconstruction using a gastric tube 14 months previously. He suddenly experienced massive hematemesis and unstable circulatory dynamics, Infusion was performed to treat critical hemorrhagic shock but was ineffective. We informed the patient and his family members of the situation, and once written informed consent to treatment was provided, we rushed him to the operating room., Diagnoses: Contrast medium permeated into the gastric cavity through a fistula between the abdominal aorta and gastric tube at the 11th thoracic level, Based on this, we made a diagnosis of AGF resulting from a peptic ulcer, and this diagnosis was further confirmed by high pressure angiography combined with computed tomography (CT) imaging., Interventions: An endovascular stent graft was placed under the guidance of digital subtraction angiography and followed by antibiotic therapy to prevent infection and proton pump inhibitor therapy to inhibit gastric acid secretion., Outcomes: The patient recovered uneventfully after the procedure. Four months after surgery, the patient died of organ failure caused by retroperitoneal lymph node metastasis and multiple intrahepatic metastases, with no postoperative bleeding linked to the endovascular stent graft repair., Lessons: Our case supports the notion that endovascular stent graft repair is a feasible alternative in treatment of AGF with several advantages in addition to surgical intervention, although more such cases should be collected and analyzed in the future to corroborate our observations., (Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Objective: The aim of this study was to determine the effects of early ecological immune-enhanced enteral nutrition on the nutritional status, immune function and intestinal mucosal barrier in patients with gastrointestinal fistulas., Patients and Methods: 54 patients with gastrointestinal fistulas were randomized to either the ecological immune-enhanced enteral nutrition group (EIEN group, 28) or the parenteral nutrition group (PN group, 26). The changes in the immunity, nutrition index and intestinal mucosal barrier indexes before the ecological immune-enhanced enteral nutrition support and at 7 days and 14 days after the ecological immune-enhanced enteral nutrition support were determined., Results: Compared with the PN group, the indexes of the CD3 and CD4 positive cells, the CD4/CD8 values and the plasma levels of IgA and IgM were significantly higher than those in EIEN group (p<0.05). Moreover, with EIEN nutritional support, the nutrition indexes, such as the plasma ALB, PA and TFN, and the intestinal mucosal barrier index (the plasma D-lactate levels and endotoxin levels), also recovered gradually to normal levels and were higher than those of the PN group (p<0.05)., Conclusions: For patients with gastrointestinal fistulas, ecological immune-enhanced enteral nutrition can not only improve the cellular immunity function, humoral immunity, and nutritional status but also enhance the intestinal mucosal barrier.

Background: Thoracogastric airway fistula (TGAF) is a rare and dangerous complication of esophagectomy performed for esophageal and cardiac carcinomas. Herein, we aimed to explore the feasibility and efficacy of individualized airway stent implantation for the treatment of TGAF after esophagectomy., Methods: Based on different TGAF types and relevant data on chest computed tomography, customized airway-covered stents were positioned so as to cover the entrance to the fistula by an interventional radiologist using fluoroscopic guidance., Results: Of the 63 patients with TGAF, 12 had thoracogastric-tracheal fistulas, 14 had thoracogastric-carinal fistulas, 21 had thoracogastric-left main bronchial fistulas, 15 had thoracogastric-right main bronchial fistulas, and 1 had a thoracogastric-right intermediate bronchial fistula. The following different stent types were placed: 7 straight self-expandable covered metallic stents, 2 hinged self-expandable covered metallic stents, 41 Y-shaped self-expandable covered metallic stents, and 13 large Y and small Y paired self-expandable covered metallic stents. In all 59 cases (93.65 %), the implantation was successful at the first attempt, with the procedure times ranging from 5 to 10 min. Esophagograms with water-soluble iodinated contrast showed that the fistulae were completely covered with no contrast flowing into the airways and lungs, and with the stents fully expanded. We recorded four cases (6.35 %) of incomplete or recurrent fistula closure., Conclusion: Customized airway-covered stents may be an appropriate palliative therapy for patients with thoracogastric airway fistula who are unfit for surgery or have a high postoperative risk.

Objective: To determine the safety and feasibility of combined-type integrated Y-shaped self-expanding covered metallic stents to treat gastrotracheal fistulas (GTFs) and gastrobronchial fistulas (GBFs)., Methods: We retrospectively reviewed the data of 10 patients with postoperative GTFs or GBFs. Depending on the size and location of the fistula and the airway diameter, we custom-designed 2 or 3 stents for each patient. The combined-type stents consisted of a large and a small Y-shaped stent. Under fluoroscopic guidance, the small stent was inserted into the distal part of the involved airway. Then, the large stent was placed at the trachea and carina. The large stent partly overlapped the main body of the small stent., Results: All stents were successfully inserted at the first attempt. Esophageal and airway radiography showed no contrast agent leakage, indicating that the fistula was fully sealed. After the procedure, the patients could resume eating without coughing, and their quality of life improved. Each patient was fully followed up. Six patients died at 3.2 to 8 months of tumors (4 patients), hemoptysis (1 patient), or pulmonary infection (1 patient). In 1 patient, the carinal fistula enlarged 4 months after stenting, and another small Y-shaped stent was inserted to seal the fistula. This patient and the remaining 3 patients are still alive., Conclusions: Deployment of the combined-type Y-shaped integrated self-expanding covered metallic stent proved to be an effective, safe, and minimally invasive procedure for complex GTFs and GBFs. Our patients tolerated the stents well and had good palliation of their symptoms., (Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Double pylorus (DP), or duplication of the pylorus, is an uncommon condition that can be either congenital or acquired. Acquired DP (ADP) occurs when a peptic ulcer erodes and creates a fistula between the duodenal bulb and the distal stomach. The clinical features and endoscopic characteristics of four patients with ADP were reviewed and compared with previously reported cases. An accessory channel connects the lesser curvature of the prepyloric antrum with the duodenal bulb, and in all cases, a peptic ulcer was located in or immediately adjacent to the accessory channel. In one of the patients, the bridge between the double-channel pylorus disappeared, resulting in a single large opening and duodenal kissing ulcer after two years and three months. Finally, nonsteroidal anti-inflammatory drugs, Helicobacter pylori and other risk factors associated with ADP are assessed.

Nowadays the development of a gastro-colic fistula is usually due to malignant disease in the gastro-intestinal tract. The symptoms can vary extensively and establishing the diagnosis quite challenging. We describe the case of a gastro-colic fistula with a complicated course and review the literature., (Copyright© Acta Chirurgica Belgica.)

Gastrobronchial fistula (GBF) is a rare surgical complication after bariatric surgery. We aimed to identify the clinical aspects of GBF and establish diagnostic and treatment strategies. A literature search was conducted in December 2013, in the PubMed electronic database. Eleven studies were selected, comprising a total of 36 patients. Most patients presented with a gastric leak prior to the diagnosis of GBF. Mean period until diagnosis was 7.2 months, and main presenting symptoms were productive cough (n = 13) and subphrenic abscess (n = 12). Endoscopic treatment was successful in 18 out of 20 patients, with minimal complication. Surgical treatment was successful in 17 cases with significant complications. GBF can be effectively treated with both endoscopic and surgical approach; however, surgical treatment can be associated with more complication.

After a sleeve gastrectomy, a leak or fistula is a serious complication. Laparoscopic drainage, drainage under US or CT scan control, or endoscopic insertion of a stent can be used, but a major re-operation is sometimes unavoidable. Endoscopic drainage with a pigtail catheter could give more success and fewer complications, but the insertion of the drain is not always possible nor does it always provide a perfect drainage. If a laparoscopic second look appears necessary, it is possible to insert a pigtail drain laparoscopically, but under endoscopic control, ensuring a correct positioning of the drain both in the peritoneal cavity and in the gastric tube. This simultaneous "rendezvous" technique could combine in this situation the advantages of purely surgical techniques and of purely endoscopic or image-guided techniques.

Background: Surgical management of gastrointestinal fistulae has been reported to carry a 30-day morbidity rate up to 82% and a mortality rate ranging from 2% to 4.8%; thus nonoperative alternatives are required. The aim of the present study was to assess the current experience on the use of cyanoacrylates in the management of these fistulae., Methods: A systematic review was carried out on Medline, Embase, The Cochrane database, Academic Search Complete, MedicLatina, and SciELO for English, Spanish, and Portuguese articles dealing with refractory fistulae by means of cyanoacrylate embolization therapy. Publication dates were restricted from 1969 to present. Outcome parameters were study design, number of participants, etiology of the fistula, approach, material used, success rate, complications, and mortality., Results: Electronic search yielded a total of 377 articles. After a meticulous screening, only 14 studies dealing with foregut/midgut fistulae and 6 addressing hindgut fistulae were included. All the included articles were prospective and retrospective case series. Cumulative success rate was 81% (range 0% to 100%) and 3 out of 203 patients (1%) developed minor complications., Conclusion: Cyanoacrylate embolization of nearly all types of refractory gastrointestinal fistulae is a feasible and harmless technique. Prospective controlled studies are required to support the available evidence., (© The Author(s) 2014.)

A 67-year-old man had a sev-ere cough and pulmonary infection for 1 wk before seeking evaluation at our hospital. He had undergone esophagectomy with gastric pull-up and radiotherapy for esophageal cancer 3 years previously. After admission to our hospital, gastroscopy and bronchoscopy revealed a fistulous communication between the posterior tracheal wall near the carina and the upper residual stomach. We measured the diameter of the trachea and bronchus and determined the site and size of the fistula using multislice computed tomography and gastroscopy. A covered self-expanding Y-shaped metallic stent was implanted into the trachea and bronchus. Subsequently, the fistula was closed completely. The patient tolerated the stent well and had good palliation of his symptoms.

Gastrointestinal fistula is the most serious complication of esophageal and gastric cardiac cancer surgery. According to occurrence of organ, gastrointestinal fistula can be divided into anastomotic fistula, gastric fistula; According to occurrence site, fistula can be divided into cervical fistula, thoracic fistula; According to time of occurrence, can be divided into early, middle and late fistula. There are special types of fistula including ‘thoracic cavity’-stomach-bronchial fistula, ‘thoracic cavity’-stomach-aortic fistula. Early diagnosis needs familiarity with various types of clinical gastrointestinal fistulas. However, Prevention of gastrointestinal fistula is better than cure, including perioperative nutritional support, respiratory tract management, and acid suppression, positive treatment of complications, antibiotic prophylaxis, and gastrointestinal decompression and eating timing. Prevention can effectively reduce the incidence of postoperative gastrointestinal fistula. Collectively, early diagnosis and treatment, nutritional supports are key to reducing mortality of gastrointestinal fistula.

Introduction: Gastrocutaneous fistulas remain an uncommon complication of upper gastrointestinal surgery. Less common but equally problematic are gastrocutaneous fistulas secondary to non-healing gastrostomies. Both are associated with considerable morbidity and mortality. Surgical repair remains the gold standard of care. For those unfit for surgical intervention, results from conservative management can be disappointing. We describe a case series of seven patients with gastrocutaneous fistulas who were unfit for surgical intervention. These patients were managed successfully in a minimally invasive manner using the Surgisis(®) (Cook Surgical, Bloomington, IN, US) anal fistula plug., Methods: Between September 2008 and January 2009, seven patients with gastrocutaneous fistulas presented to Wishaw General Hospital. Four gastrocutaneous fistulas represented non-healing gastrostomies, two followed an anastomotic leak after an oesophagectomy and one following an anastomotic leak after a distal gastrectomy. All patients had poor nutritional reserve with no other identifiable reason for failure to heal. All were deemed unfit for surgical intervention. Five gastrocutaneous fistulas were closed successfully using the Surgisis(®) anal fistula plug positioned directly into the fistula tract under local anaesthesia and two gastrocutaneous fistulas were closed successfully using the Surgisis(®) anal fistula positioned endoscopically using a rendezvous technique., Results: For the five patients with gastrocutaneous fistulas closed directly under local anaesthesia, oral alimentation was reinstated immediately. Fistula output ceased on day 12 with complete epithelialisation occurring at a median of day 26. For the two gastrocutaneous fistulas closed endoscopically using the rendezvous technique, oral alimentation was reinstated on day 5 with immediate cessation of fistula output. Follow-up upper gastrointestinal endoscopy confirmed re-epithelialisation at eight weeks. In none of the cases has there been fistula recurrence (range of follow-up duration: 30-59 months)., Conclusions: Surgisis(®) anal fistula plugs can be used safely and effectively to close gastrocutaneous fistulas in a minimally invasive manner in patients unfit for surgical intervention.

A 63-year-old woman was referred to our hospital for further examination because of an incidental finding of early gastric cancer. Endoscopic submucosal dissection (ESD) was successfully performed for complete resection of the tumor. On the first post-ESD day, the patient suddenly complained of abdominal pain after an episode of vomiting. Abdominal computed tomography (CT) showed delayed perforation after ESD. The patient was conservatively treated with an intravenous proton pump inhibitor and antibiotics. On the fifth post-ESD day, CT revealed a gastric wall abscess in the gastric body. Gastroscopy revealed a gastric fistula at the edge of the post-ESD ulcer, and pus was found flowing into the stomach. An intradrainage stent and an extradrainage nasocystic catheter were successfully inserted into the abscess for endoscopic transgastric drainage. After the procedure, the clinical symptoms and laboratory test results improved quickly. Two months later, a follow-up CT scan showed no collection of pus. Consequently, the intradrainage stent was removed. Although the gastric wall abscess recurred 2 wk after stent removal, it recovered soon after endoscopic transgastric drainage. Finally, after stent removal and oral antibiotic treatment for 1 mo, no recurrence of the gastric wall abscess was found.

A 36-year-old male Asian immigrant with a history of hepatitis B and hepatitis C related unresectable hepatocellular carcinoma in the left lobe of the liver presented with hematemesis and severe anemia. He was diagnosed with a liver mass that was resected 8 years ago described as a benign tumor in his home country. He had received trans-arterial chemoembolization (TACE) four months ago after subsequent diagnosis of unresectable hepatoma, and currently was receiving chemotherapy with Sorafenib. After resuscitation, a contrast enhanced computerized tomography was performed which showed fistulization of hepatocellular carcinoma into adjacent stomach. This finding was confirmed during endoscopy with direct visualization of the fistulous opening. Hepatocellular carcinoma (HCC) invading the gastrointestinal (GI) tract is rare. We present a case and literature review of HCC with local invasion of the stomach causing massive upper GI bleeding after receiving TACE.