Use of an over-the-scope clip for endoscopic sealing of a gastric fistula after sleeve gastrectomy.

the gastrointestinal tract is a serious complication. A gastrocutaneous fistula after sleeve gastrectomy is difficult to treat, with a mortality rate of 85% following unsuccessful treatment [1]. These fistulas have been successfully managed with endoscopic fibrin sealing [2]. Preliminary experience with the over-the-scope clipping system (Ovesco, Tubingen, Germany) has shown the efficacy of this intervention in the management of severe bleeding and perforations of the gastrointestinal tract [3–5]. This is the first report of the use of an over-the-scope clipping for the management of a gastric fistula. A 43-year-old woman underwent sleeve gastrectomy for morbid obesity. After 1 week, a fistula developed at the proximal end of the suture, 2 cm distal to the esophagogastric junction. A nasogastric drain and an ultrasound-guided external drain were inserted. Endoscopy showed a 7-mm orifice (●" Fig. 1).●" Fig. 2 shows the extravasion of contrast medium, confirming the presence of a fistula. Two attempts to seal the fistula with hemoclips failed. Placement of a large, colorectal expandable covered stent (Taewoong, Korea) was also attempted. The patient could not eat and complained of severe epigastric pain. The stent was removed 3 weeks later. Surgery was carried out, but the fistula reappeared 1week later and a gastrocutaneous fistula was diagnosed. The over-the-scope clipping system was used to overcome the limitations presented by the available hemoclips. The overthe-scope clip is delivered by means of an applicator cap placed on the tip of the endoscope. A catheter with a retractable anchor was introduced through the fistula and the grasped tissue firmly pulled inside the cap (●" Fig. 3 and 4). The clip was then released and the fistula successfully closed. The patient was allowed to eat her usual diet 24 hours later after post-treatment evaluation. She was then discharged. The endoscopic and radiologic controls performed after 1 and 2 weeks confirmed sealing of the fistula (●" Fig. 5).