Suture traction-assisted bearclaw fistula closure: a case series describing a novel endoscopic technique for fistula closure

Abstract

Background and aims: Endoscopic therapies are currently the mainstay of treatment for GI fistulas. However, some GI fistulas are hard to treat as the result of the tissue's friability and large size defect. This case series describes a novel technique for managing hard-to-treat fistulas.

Methods: Using an endosuturing device, we strategically obtain full-thickness bites at various points around the fistula opening. After each bite, the anchor is released, and a new suture thread is loaded into the suturing device for another bite at a different point. These sutures are intentionally left untightened, remaining loose within the GI tract. Subsequently, the scope is withdrawn, leaving the sutures extending outside the patient. In using a dual-channel scope, we mount an over-the-scope clip on the scope, and the suture threads are captured through one of the scope channels using a snare. The endoscope is reintroduced. Traction is then applied to the suture threads, allowing healthy tissue to be drawn outside the fistula, forming a flap. Once enough tissue is pulled inside the over-the-scope cap, the clip is deployed, creating an occlusive patch and effectively sealing the fistulous tract.

Results: We present 3 cases of GI fistulas that failed to close using traditional endoscopic techniques. The first case is that of a 78-year-old man with a history of bladder cancer treated with radical cystectomy and neobladder construction, as well as a long history of ulcerative colitis resulting in a rectovesicular fistula. The second case is of a 68-year-old man with a history of gastric cancer treated with partial gastrectomy and gastrojejunostomy complicated by jejunocolonic fistula formation. The third patient is a 30-year-old man with a history of cerebral palsy who relies on enteral feeding via jejunostomy, with gastrocutaneous fistula formation at the previous gastrostomy tube site.

Conclusions: We presented 3 successful applications of this novel technique, each with a 9- to 13-month follow-up showing no recurrence or adverse events. This technique offers a promising solution for challenging fistulas that resist closure with standard procedures.

Figure 1

Suture pattern on the basis of the size of the defect.

Figure 2

Schematic diagram illustrating the technique in detail. A, Sutures are placed at different quadrants surrounding the defect. B, Sutures are not cinched; they are extended through the mouth after scope withdrawal. An OTSC is mounted on the scope, and a snare is introduced through one of the channels. C, Suture threads are passed within the scope channel using the snare. D and E, The scope is reintroduced while the sutures are secured through the working channel. F and G, Once an adequate amount of healthy full-thickness tissue is pulled inside the clip cap, the OTSC is deployed, fully closing the fistulous tract. OTSC, Over-the-scope clip.

Figure 3

Case of a rectovesicular fistula. A, Large open fistula between the rectum and neobladder. B, Over-the-scope clip fully closing the fistulous tract.

Figure 4

Case of a jejunocolonic fistula. A, Large open fistula between the jejunum and colon. B, Traction is applied to the suture threads, pulling healthy tissue outside the fistula. C, Over-the-scope clip fully closing the fistulous tract.

Figure 5

Case of a gastrocutaneous fistula. A, Large gastrocutaneous fistula connecting the stomach to the skin. B, Traction is applied to the suture threads, pulling healthy tissue outside the fistula. C, Over-the-scope clip fully closing the fistulous tract.