Endoscopic closure of gastrogastric fistulas by using a tissue apposition system (with videos)

Background: Gastrogastric fistulas (GGFs) are seen in 1.5% to 12.5% of patients after Roux-en-Y gastric bypass (RYGB) bariatric surgery, often leading to failure to lose adequate weight. Objective: The aim of this study was to assess the feasibility, safety, and percentage of successful primary endoluminal closures of GGFs by using a recently developed tissue apposition system in combination with local mucosectomy. Design: A feasibility and outcome study following institutional review board protocol. Setting: Tertiary referral teaching hospital, Legacy Health System, Portland, Oregon. Interventions: A combination of mucosectomy and nonresorbable tissue apposition is used to achieve a permanent closure of the GGF. Patients: Four patients with 5 GGFs after RYGB; the mean fistula diameter of was 18.6 mm (range 10-30 mm). Results: Primary closure rate (1 endoscopic session) of 5 GGFs was 100%. The mean procedure time was 88.5 minutes. One to 4 pairs of tissue anchors were used to close the fistulas. The mean time for performing mucosectomy was 21.6 minutes (range 8-42 minutes) and 39.6 minutes (range 12-58 minutes) for fistula closure. Estimated blood loss was on average 2 mL (range 0-5 mL). No complications were recorded. Early success (3 months), as evidenced by early satiety and weight loss, was noted for 3 of 4 patients. After 3 months, only the smallest fistula (10 mm) was still completely closed, and after 6 months, it also showed a pinhole opening. Conclusion: It was feasible to close all fistulas endoscopically without complications. Permanent closure of GGFs could not be achieved.