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First report of endoscopic closure of a gastrocolic fistula using an over-the-scope clip system (with video)
AT THE FOCAL POINT
Lawrence J. Brandt, MD, Associate Editor for Focal Points
First report of endoscopic closure of a gastrocolic fistula using an overthe-scope clip system (with video)
A 41-year-old man with cerebral palsy was referred to our institution with a gastrocolic fistula (GCF) secondary to migration of a PEG tube from the stomach into the transverse colon (TC). The GCF, which was confirmed by CT (A), manifested as intense halitosis and profuse diarrhea upon PEG feeding. At EGD, the GCF was seen to involve the greater curvature of the stomach (B). Intubation of the fistulous tract allowed removal of the PEG bumper, which lay within the TC. An over-the-scope clip system (OTSC) (Ovesco AG, Tuebingen, Germany) was mounted onto the gastroscope (C). Once the gastric margins of the GCF were drawn into the OTSC cap by use of a dedicated anchor, clip release successfully closed the GCF (D; Video 1, available online at www.giejournal.org). At 3 months’ follow-up, the diarrhea and intense halitosis have not recurred, confirming successful resolution of the GCF and obviating the need for further investigation. www.giejournal.org
DISCLOSURE All authors disclosed no financial relationships relevant to this publication.
Alberto Murino, MD, Edward J. Despott, MD, MRCP, Wolfson Unit for Endoscopy, Carolynne Vaizey, MD, FRCS, Gareth Bashir, MD, FRCS, Department of Surgery, Anika Hansmann, MD, FRCR, Arun Gupta, MD, FRCR, Department of Radiology, St Mark’s Hospital and Academic Institute, Imperial College London, Krysia Konieczko, MD, FRCA, Department of Anaesthesia, St Mark’s Hospital, North West London Hospitals NHS Trust, London, Chris Fraser, MD, MRCP, Wolfson Unit for Endoscopy, St Mark’s Hospital and Academic Institute, Imperial College London, London, United Kingdom doi:10.1016/j.gie.2011.12.013
Volume 75, No. 4 : 2012 GASTROINTESTINAL ENDOSCOPY 893
At the Focal Point
Commentary I just gave a lecture on anatomy of the GI tract to the first-year students at our medical school. The central theme of my presentation was that knowledge of the anatomic relationships among adjacent organs can help to predict clinical presentations and complications of a variety of GI and non-GI diseases. Thus, for example, I detailed the anatomic relationships the stomach has with the gallbladder, liver, pancreas, left kidney, spleen, aorta, and, of course, transverse colon, illustrating each relationship with an example of disease process. For the colon, I showed two GCFs, one from gastric ulcer and one from colon cancer at the splenic flexure; I could have used this case as well. Interposition of the TC between the stomach and the abdominal wall leads to a GCF in 2% to 3.5% of PEG insertions, and I remember quite well a GCF that developed in a PEG I placed (of course into a hospital VIP) a very long time ago. Knowing the anatomy doesn’t necessarily protect one from such complications, for all of us that have been in the practice of Medicine for more than a few years know that if one performs procedures long enough, bad things happen, even when all has been performed properly. This patient’s clinical symptoms alone enabled diagnosis: diarrhea upon PEG feeding and halitosis. In time, it would not be unexpected that diarrhea could have become persistent as colon contents flowed into the stomach and down the small intestine, leading to bacterial overgrowth. The authors of this Focal Point, however, interceded and corrected the problem using an OTSC system, which may represent in these patients a minimally invasive and costeffective alternative to surgery. Macte virtute, bravo, well-done! Lawrence J. Brandt, MD Associate Editor for Focal Points
A rare cause of hematemesis: gastric metastases from renal cell carcinoma
A 45-year-old woman underwent a nephrectomy for renal cell carcinoma (RCC) in 2000. No adjuvant therapy was given, and she was followed yearly with no further treatment. In 2008, she began anticoagulation therapy because of aortic valve replacement and was admitted to the hospital a year later with severe anemia (4.7 g/dL) without visible bleeding. A CT scan of the chest, abdomen, and pelvis revealed pulmonary and ovarian metastases. Nine days later, the patient presented with hematemesis requiring resuscitation and underwent an inconclusive endoscopy (because of blood clots). Oral anticoagulation therapy was suspended, and a repeat endoscopy revealed a 2-cm raised lesion with central ulceration in the body of the stomach (A-C). Histologic examination revealed neo894 GASTROINTESTINAL ENDOSCOPY Volume 75, No. 4 : 2012
plastic involvement of the gastric mucosa with RCC metastasis. The patient immediately began treatment with sunitinib, but died 4 months later.
DISCLOSURE The authors disclosed no financial relationships relevant to this publication. Susana Rodrigues, MD, Pedro Bastos, MD, Guilherme Macedo, MD, PhD, FACG, FASGE, Department of Gastroenterology, Hospital São João, Porto, Portugal doi:10.1016/j.gie.2012.01.025
www.giejournal.org
Lawrence J. Brandt, MD, Associate Editor for Focal Points
First report of endoscopic closure of a gastrocolic fistula using an overthe-scope clip system (with video)
A 41-year-old man with cerebral palsy was referred to our institution with a gastrocolic fistula (GCF) secondary to migration of a PEG tube from the stomach into the transverse colon (TC). The GCF, which was confirmed by CT (A), manifested as intense halitosis and profuse diarrhea upon PEG feeding. At EGD, the GCF was seen to involve the greater curvature of the stomach (B). Intubation of the fistulous tract allowed removal of the PEG bumper, which lay within the TC. An over-the-scope clip system (OTSC) (Ovesco AG, Tuebingen, Germany) was mounted onto the gastroscope (C). Once the gastric margins of the GCF were drawn into the OTSC cap by use of a dedicated anchor, clip release successfully closed the GCF (D; Video 1, available online at www.giejournal.org). At 3 months’ follow-up, the diarrhea and intense halitosis have not recurred, confirming successful resolution of the GCF and obviating the need for further investigation. www.giejournal.org
DISCLOSURE All authors disclosed no financial relationships relevant to this publication.
Alberto Murino, MD, Edward J. Despott, MD, MRCP, Wolfson Unit for Endoscopy, Carolynne Vaizey, MD, FRCS, Gareth Bashir, MD, FRCS, Department of Surgery, Anika Hansmann, MD, FRCR, Arun Gupta, MD, FRCR, Department of Radiology, St Mark’s Hospital and Academic Institute, Imperial College London, Krysia Konieczko, MD, FRCA, Department of Anaesthesia, St Mark’s Hospital, North West London Hospitals NHS Trust, London, Chris Fraser, MD, MRCP, Wolfson Unit for Endoscopy, St Mark’s Hospital and Academic Institute, Imperial College London, London, United Kingdom doi:10.1016/j.gie.2011.12.013
Volume 75, No. 4 : 2012 GASTROINTESTINAL ENDOSCOPY 893
At the Focal Point
Commentary I just gave a lecture on anatomy of the GI tract to the first-year students at our medical school. The central theme of my presentation was that knowledge of the anatomic relationships among adjacent organs can help to predict clinical presentations and complications of a variety of GI and non-GI diseases. Thus, for example, I detailed the anatomic relationships the stomach has with the gallbladder, liver, pancreas, left kidney, spleen, aorta, and, of course, transverse colon, illustrating each relationship with an example of disease process. For the colon, I showed two GCFs, one from gastric ulcer and one from colon cancer at the splenic flexure; I could have used this case as well. Interposition of the TC between the stomach and the abdominal wall leads to a GCF in 2% to 3.5% of PEG insertions, and I remember quite well a GCF that developed in a PEG I placed (of course into a hospital VIP) a very long time ago. Knowing the anatomy doesn’t necessarily protect one from such complications, for all of us that have been in the practice of Medicine for more than a few years know that if one performs procedures long enough, bad things happen, even when all has been performed properly. This patient’s clinical symptoms alone enabled diagnosis: diarrhea upon PEG feeding and halitosis. In time, it would not be unexpected that diarrhea could have become persistent as colon contents flowed into the stomach and down the small intestine, leading to bacterial overgrowth. The authors of this Focal Point, however, interceded and corrected the problem using an OTSC system, which may represent in these patients a minimally invasive and costeffective alternative to surgery. Macte virtute, bravo, well-done! Lawrence J. Brandt, MD Associate Editor for Focal Points
A rare cause of hematemesis: gastric metastases from renal cell carcinoma
A 45-year-old woman underwent a nephrectomy for renal cell carcinoma (RCC) in 2000. No adjuvant therapy was given, and she was followed yearly with no further treatment. In 2008, she began anticoagulation therapy because of aortic valve replacement and was admitted to the hospital a year later with severe anemia (4.7 g/dL) without visible bleeding. A CT scan of the chest, abdomen, and pelvis revealed pulmonary and ovarian metastases. Nine days later, the patient presented with hematemesis requiring resuscitation and underwent an inconclusive endoscopy (because of blood clots). Oral anticoagulation therapy was suspended, and a repeat endoscopy revealed a 2-cm raised lesion with central ulceration in the body of the stomach (A-C). Histologic examination revealed neo894 GASTROINTESTINAL ENDOSCOPY Volume 75, No. 4 : 2012
plastic involvement of the gastric mucosa with RCC metastasis. The patient immediately began treatment with sunitinib, but died 4 months later.
DISCLOSURE The authors disclosed no financial relationships relevant to this publication. Susana Rodrigues, MD, Pedro Bastos, MD, Guilherme Macedo, MD, PhD, FACG, FASGE, Department of Gastroenterology, Hospital São João, Porto, Portugal doi:10.1016/j.gie.2012.01.025
www.giejournal.org