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Gastric fistula formation is a known complication of bariatric surgery. Many gastric fistulae can be managed endoscopically, however, it can be difficult to successfully treat chronic fistulae. New techniques such as cardiac septal occluders continue to add to the endoscopic arsenal for fistula closure. A drawback of cardiac septal occluders is their large diameter. Vascular plugs come in smaller diameters and can therefore be deployed into smaller fistulae. We present a video demonstration of vascular plug deployment for gastrointestinal fistulae closure.

Endoscopic Methods:
Our case series focuses on vascular plug deployment for management of gastro-bronchial and gastro-gastric fistulae that were refractory to traditional management (including over-the-scope suturing, through-the-scope helical tack placement, endoscopic internal drainage, and endoscopic diversion therapy). In our cases fistulae were small, measuring 3 mm to 4mm in diameter, respectively.

Vascular plug manufacturers recommend that the plug diameter should measure 50% larger than the target lumen. Thus, for both cases we chose to deploy a 6 mm by 6 mm vascular plug. The vascular plug is made of a nitinol mesh and is attached to a delivery wire via a screw attachment. Advancing or retracting the delivery wire advances or recaptures the vascular plug. Once in position, counterclockwise torque of the delivery wire unscrews the vascular plug and releases it. The vascular plug comes loaded on a 100 cm delivery wire, which prevents deployment through the endoscopic working channel. Therefore, we use a modified 10-7-5 biliary dilation catheter to deliver the vascular plug. The catheter is altered by modifying the distal tapered end to allow for plug deployment and then modifying the proximal end to accommodate the 100 cm delivery wire. These modifications also allow for the plug to be inserted into the catheter.

In our cases, pre-procedurally patients with gastro-bronchial and gastro-gastric fistulae reported significant coughing and reflux respectively. Vascular plug deployment in both cases was technically successful and clinically successful as both patients immediately had improvement in symptoms and a subsequent durable response.

Conclusion:
This case series highlights the use of vascular plug devices as feasible alternate endoscopic therapies for gastric fistulae closure where other established techniques have failed. In two cases of difficult-to-manage gastric fistulae, closure was achieved using vascular plugs and modified versions of available endoscopic tools. Both patients achieved symptomatic resolution and avoided the need for surgical intervention. Further study is needed to better analyze the potential benefits and limitations of these interventions as well as long-term clinical outcomes.

Dimitri Belkin

Appearances

CATHETER-BASED DEPLOYMENT OF VASCULAR PLUGS FOR THE MANAGEMENT OF GASTRIC FISTULAE

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