- Email: [email protected]
A novel technique for over-the-scope clip application: a safer and more secure method
VideoGIE
A novel technique for over-the-scope clip application: a safer and more secure method
Figure 1. Over-the-scope 12/6t closure of a gastrocutaneous fistula by using ERCP guidewire placement and external pressure to increase mucosal purchase.
Persistent gastrocutaneous fistula (GCF) is an adverse event after removal of a gastrostomy tube, occurring in 2% to 44% of patients. Gastrostomy placement for longer than 9 months is the only identified risk factor. Nonoperative techniques have been described to close a GCF, including topical silver nitrate (46%), endoscopic band ligation (75%), and use of over-the-scope clips (OTSCs) (100%). Despite a high primary success rate of GCF closure with OTSCs, there are reports of recurrent drainage caused by a shift in location of the clip or spontaneous dislodgment. At our institution, there was an inadvertently placed OTSC causing gastric outlet obstruction requiring endoscopic removal. The traditional OTSC technique involves the use of assistive devices that are used to pull tissue back into the cap, allowing for increased mucosal adherence. We have found these assistive devices to be cumbersome and have relied on suction of the mucosal defect into the cap. However, we developed a technique that uses external digital pressure at the GCF site along with percu-
This video can be viewed directly from the GIE website or by using the QR code and your mobile device. Download a free QR code scanner by searching “QR Scanner” in your mobile device’s app store.
1006 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 4 : 2015
taneous guidewire localization (Fig. 1, Video 1, available online at www.giejournal.org) to ensure both accuracy of OTSC placement and definitive mucosal adherence.
CASE PRESENTATION A 91-year-old man was referred for closure of a GCF. He had a paraesophageal mass with benign behavior. A PEG tube was placed for nutrition and removed 13 months later. He had a high-volume GCF persisting for more than 3 months after gastrostomy removal.
DISCLOSURE The following author disclosed financial relationships relevant to this article: Dr Kochman is a consultant to Cook and Boston Scientific. All other authors disclosed no financial relationships relevant to this article. Brian Riff, MD,1 Michael Kochman, MD,1,2 Division of Gastroenterology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania (1), Center for Endoscopic Innovation, Research, and Training (2), Philadelphia, Pennsylvania, USA
http://dx.doi.org/10.1016/j.gie.2014.06.041
www.giejournal.org
A novel technique for over-the-scope clip application: a safer and more secure method
Figure 1. Over-the-scope 12/6t closure of a gastrocutaneous fistula by using ERCP guidewire placement and external pressure to increase mucosal purchase.
Persistent gastrocutaneous fistula (GCF) is an adverse event after removal of a gastrostomy tube, occurring in 2% to 44% of patients. Gastrostomy placement for longer than 9 months is the only identified risk factor. Nonoperative techniques have been described to close a GCF, including topical silver nitrate (46%), endoscopic band ligation (75%), and use of over-the-scope clips (OTSCs) (100%). Despite a high primary success rate of GCF closure with OTSCs, there are reports of recurrent drainage caused by a shift in location of the clip or spontaneous dislodgment. At our institution, there was an inadvertently placed OTSC causing gastric outlet obstruction requiring endoscopic removal. The traditional OTSC technique involves the use of assistive devices that are used to pull tissue back into the cap, allowing for increased mucosal adherence. We have found these assistive devices to be cumbersome and have relied on suction of the mucosal defect into the cap. However, we developed a technique that uses external digital pressure at the GCF site along with percu-
This video can be viewed directly from the GIE website or by using the QR code and your mobile device. Download a free QR code scanner by searching “QR Scanner” in your mobile device’s app store.
1006 GASTROINTESTINAL ENDOSCOPY Volume 81, No. 4 : 2015
taneous guidewire localization (Fig. 1, Video 1, available online at www.giejournal.org) to ensure both accuracy of OTSC placement and definitive mucosal adherence.
CASE PRESENTATION A 91-year-old man was referred for closure of a GCF. He had a paraesophageal mass with benign behavior. A PEG tube was placed for nutrition and removed 13 months later. He had a high-volume GCF persisting for more than 3 months after gastrostomy removal.
DISCLOSURE The following author disclosed financial relationships relevant to this article: Dr Kochman is a consultant to Cook and Boston Scientific. All other authors disclosed no financial relationships relevant to this article. Brian Riff, MD,1 Michael Kochman, MD,1,2 Division of Gastroenterology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania (1), Center for Endoscopic Innovation, Research, and Training (2), Philadelphia, Pennsylvania, USA
http://dx.doi.org/10.1016/j.gie.2014.06.041
www.giejournal.org