Identification of the fistula. The suture line of the prior sleeve gastrectomy is identified and followed proximally, to a focal area of nodularity with inflammatory pseudopolyps in the anastomotic scar. Moving proximally towards the GE junction, the gastric opening of the fistula is clearly identified in the greater curvature of the stomach. The picture shows a steady view of this opening.
Contrast injection into the opening to identify the fistulous tract. Using a Haber ramp and fluoroscopic guidance, a guidewire is passed through the gastric opening into the fistula and advanced to the pleural space, confirming the entire fistulous tract. Once in place, contrast is injected and the extravasation is seen in 3 different points: the stomach, the pleural space and the thoracostomy tube that has been previously placed.
Passage of a cytology brush into the tract to create tissue abrasion. A special biliary sampling brush was used for this part of the procedure . As seen here, this device is characterized by the presence of two sets of stiff bristles in black interspaced with softer bristles in white. The purpose of using this device was to create tissue abrasion of the fistulous tract with the stiff bristles to evoke a localized inflammatory response that would in turn lead to fibrosis and therefore facilitate the closure of fistula. The brush was carefully introduced into the tract under fluoroscopic guidance. Note that the stiff bristles are radiopaque to provide the endoscopist with a reference point when advancing the device. Several passes of the brush were performed in order to create the desired degree of inflammation
Thermocoagulation of the gastric opening. Using the argon plasma coagulation catheter, the gastric opening of the fistula was carefully cauterized. The reason for performing APC at the gastric opening of the fistula, was to create a more solid area of tissue. This would in turn decrease the probability of the clip from falling off after completion of the procedure.
Injection of human fibrin sealant into the fistulous tract. This plasma derived Human fibrin sealant is commonly used in surgery to achieve hemostasis in areas of diffuse bleeding. The product contains an injecting device and two vials. One with fibrinogen and the other one with thrombin. Both in frozen solution forms. After the solutions are thawed, they are drawn into a unique trilumen catheter application device. This device contains two syringe lumens and one air lumen for spraying. The solutions mix as they exit the catheter at the time of administration and once in contact with the exposed tissue, the mix polymerizes and creates a topical hemostatic seal.
Deployment of the over the scope clip. The device was preloaded to the tip of the endoscope and the entire system was then advanced to the gastric opening of the fistula. Gentle suction was applied to grasp the tissue into the cap, to allow an adequate deployment of the grasping device. The clip was then deployed successfully, closing the gastric opening of the fistula. The fluoroscopy image shows the clip holding the tissue.
Antonio Mendoza Ladd, MD, Lenox Hill Hospital
Paresh Shah, MD, Lenox Hill Hospital
Gregory Haber, MD, Lenox Hill Hospital