Suture traction—assisted bearclaw fistula closure: a case series describing a novel endoscopic technique for fistula closure

Abstract

Background and Aims

Endoscopic therapies are currently the mainstay of treatment for GI fistulas. However, some GI fistulas are hard to treat as the result of the tissue's friability and large size defect. This case series describes a novel technique for managing hard-to-treat fistulas.

Methods

Using an endosuturing device, we strategically obtain full-thickness bites at various points around the fistula opening. After each bite, the anchor is released, and a new suture thread is loaded into the suturing device for another bite at a different point. These sutures are intentionally left untightened, remaining loose within the GI tract. Subsequently, the scope is withdrawn, leaving the sutures extending outside the patient. In using a dual-channel scope, we mount an over-the-scope clip on the scope, and the suture threads are captured through one of the scope channels using a snare. The endoscope is reintroduced. Traction is then applied to the suture threads, allowing healthy tissue to be drawn outside the fistula, forming a flap. Once enough tissue is pulled inside the over-the-scope cap, the clip is deployed, creating an occlusive patch and effectively sealing the fistulous tract.

Results

We present 3 cases of GI fistulas that failed to close using traditional endoscopic techniques. The first case is that of a 78-year-old man with a history of bladder cancer treated with radical cystectomy and neobladder construction, as well as a long history of ulcerative colitis resulting in a rectovesicular fistula. The second case is of a 68-year-old man with a history of gastric cancer treated with partial gastrectomy and gastrojejunostomy complicated by jejunocolonic fistula formation. The third patient is a 30-year-old man with a history of cerebral palsy who relies on enteral feeding via jejunostomy, with gastrocutaneous fistula formation at the previous gastrostomy tube site.

Conclusions

We presented 3 successful applications of this novel technique, each with a 9- to 13-month follow-up showing no recurrence or adverse events. This technique offers a promising solution for challenging fistulas that resist closure with standard procedures.

Background

GI fistulas form between the GI epithelium and another organ. The etiology, anatomy, and patient-specific factors influence the management of these fistulas.¹ Initially, these fistulas were managed surgically. However, surgery was associated with high morbidity and mortality. As a result, endoscopic therapies started to emerge and were associated with better outcomes.² However, these fistulas can be challenging to manage with these traditional techniques. Our case series describes a novel technique for managing these hard-to-treat fistulas. We have named this technique suture traction—assisted bearclaw (STAB) fistula closure.

Endoscopic method

Using an endosuturing device, we strategically obtain full-thickness bites at various points 5 to 10 mm from the fistula opening. Depending on the size of the defect, the number of sutures and the pattern vary (Fig. 1). After each bite, the anchor is released, and a new suture is loaded into the suturing device for another bite at a different point. These sutures are intentionally left uncinched, allowing them to remain loose within the GI tract. Subsequently, the scope is withdrawn, leaving the sutures extending outside the patient. These deep tissue samples serve as robust anchoring points for traction and facilitate the creation of a flap. In using a dual-channel scope, we mount an over-the-scope (OTSC) clip on the scope, and the suture threads are grabbed through one of the scope channels using a snare. After this, the endoscope is reintroduced. Traction is then applied to the suture threads, allowing healthy tissue to be drawn outside the fistula, forming a flap. Once enough tissue is pulled inside the OTSC cap and the fistula tract is no longer visible, the OTSC is deployed, creating an occlusive patch, and effectively sealing the fistulous tract. The suture threads are then cut with the endoscopic scissors, and the scope is withdrawn. A detailed illustration of the technique is presented in Figure 2 and demonstrated in the ex vivo video (Video 1, available online at www.videogie.org).

Figure 1.

Suture pattern on the basis of the size of the defect.

Figure 2.

Schematic diagram illustrating the technique in detail. A, Sutures are placed at different quadrants surrounding the defect. B, Sutures are not cinched; they are extended through the mouth after scope withdrawal. An OTSC is mounted on the scope, and a snare is introduced through one of the channels. C, Suture threads are passed within the scope channel using the snare. D and E, The scope is reintroduced while the sutures are secured through the working channel. F and G, Once an adequate amount of healthy full-thickness tissue is pulled inside the clip cap, the OTSC is deployed, fully closing the fistulous tract. OTSC, Over-the-scope clip.

Case presentation

Case of rectovesicular fistula

The first case is a 78-year-old man with a history of bladder cancer treated with radical cystectomy and neobladder construction, as well as a long history of ulcerative colitis complicated by a rectovesicular fistula formation. The initial colonoscopy revealed a rectovesicular fistula 7 cm from the anal verge. Argon plasma coagulation (APC) was used to promote granulation tissue formation, followed by suturing and clipping, resulting in partial closure. A repeat colonoscopy a few days later involved another attempt at closure with the suturing system, which showed limited success. This time, the patient underwent a flexible sigmoidoscopy, during which the previously described rectovesicular fistula between the rectum and the neobladder was noted to be open (Fig. 3A). Using an endosuturing device, full-thickness sutures were taken from a rim of healthy intestinal tissue in the neobladder at 8 distinct points. The anchor is released after each bite, and the process is repeated with every suture. The sutures were not cinched; they were all left loose inside the patient, and the scope was withdrawn with the suture threads extending outside the patient. An OTSC was then mounted on the dual-channel therapeutic scope, and the sutures were grabbed with a snare through one of the scope channels. The scope was then reintroduced. Healthy-appearing small-bowel tissue was pulled outside the fistula by achieving coordinated pulling force on the different endosutures. Once the amount of tissue was adequate, the fistula was no longer noticeable, and the OTSC was fired, achieving a patch that appeared to be water-sealed after testing (Fig. 3B). The procedure lasted 1 hour, and no adverse events were encountered. A repeat colonoscopy conducted 10 months later did not show a visible fistulous tract, supporting the successful closure of the fistula.

Figure 3.

Case of a rectovesicular fistula. A, Large open fistula between the rectum and neobladder. B, Over-the-scope clip fully closing the fistulous tract.

Case of jejunocolonic fistula

A 68-year-old man with a history of gastric cancer treated with partial gastrectomy and gastrojejunostomy presented to the emergency department for persistent epigastric abdominal pain. The patient underwent EGD for endoscopic evaluation, which showed an anatomy consistent with the patient's known history of Billroth II. A jejunocolonic fistula was noted anteriorly, distal to the site of anastomosis. The scope was advanced into the colon through the fistula, and an attempt to close the fistula using the suturing device was performed. The fistula mucosa was ablated circumferentially using APC to promote tissue fibrosis. However, after the procedure, the patient reported having worsened diarrhea and weight loss. A repeated EGD showed a persistent jejunocolonic fistula anterior to the site of anastomosis (Fig. 4A). The scope was advanced into the colon through the fistula, and the mucosa was ablated using APC circumferentially. Similarly, using an endosuturing device, 4 different sutures were applied at the 4 quadrants of the jejunocolonic fistula. The scope was then withdrawn, and the suture threads were pulled through the mouth. After mounting an OTSC on the scope, the outer end of the suture threads was pulled through the scope using a snare (Fig. 4B). The threads were used to provide tissue approximation of the fistula. After pulling tension is exerted on the suture threads, a 14-mm OTSC was applied successfully and fully closed the fistula (Fig. 4C). The patient tolerated the procedure without any adverse events. The patient's symptoms have not recurred after multiple follow-up visits at 3, 6, and 12 months, indicating the successful closure of the fistula.

Figure 4.

Case of a jejunocolonic fistula. A, Large open fistula between the jejunum and colon. B, Traction is applied to the suture threads, pulling healthy tissue outside the fistula. C, Over-the-scope clip fully closing the fistulous tract.

Case of gastrocutaneous fistula

A 30-year-old man with a history of cerebral palsy with quadriplegia, tracheostomy, and dependence on a ventilator presented to the emergency department with abdominal wall leakage. The patient had a previous admission for PEG tube leakage, which was nonresolved when exchanged with a smaller PEG tube. At that time, the PEG tube was removed with percutaneous jejunostomy placement. The PEG tube site was closed using endosutures. However, on this admission, the patient presents with leakage from his previous PEG tube site. EGD showed the presence of a gastrocutaneous fistula at the previous PEG tube site (Fig. 5A). Four different sutures were obtained around the ostomy in 4 quadrants using the suturing device. A suture was taken at the 12-o'clock position. The anchor was dropped after taking a full-thickness bite, and this was repeated at the 3-, 6-, and 9-o'clock quadrants. The scope was removed with the endosuturing device on it. The endosuturing device was removed from the dual-channel scope, and an OTSC was mounted. The sutures were then grabbed together using a snare outside the patient, and the scope was introduced to the stomach while tension was applied on the snare, pulling the sutures back through the scope channel (Fig. 5B). Once inside the stomach, pulling tension was exerted on the different quadrants to achieve adequate approximation within the over-the-scope cap. The OTSC was then deployed once it was deemed that the tissue pulled was sufficient to achieve complete fistula closure (Fig. 5C). Water immersion then showed no leaks at the skin surface, supporting the successful closure of the fistula. The procedure lasted 1 hour, was well tolerated, and no adverse events emerged. At the 13-month follow-up, the patient's skin remained intact, showing no evidence of the fistulous tract (Video 2, available online at www.videogie.org).

Figure 5.

Case of a gastrocutaneous fistula. A, Large gastrocutaneous fistula connecting the stomach to the skin. B, Traction is applied to the suture threads, pulling healthy tissue outside the fistula. C, Over-the-scope clip fully closing the fistulous tract.

Discussion

GI fistulas are serious adverse events with high mortality and morbidity rates. They most frequently develop after surgical interventions but can also occur spontaneously in inflammatory bowel disease, malignancy, or after radiation therapy.³ To date, numerous endoscopic interventions are available for managing fistulas. These include the placement of stents, using endoscopic vacuum therapy, using clips for leak closure, performing endoluminal suturing, applying tissue adhesives for sealing, or using a combination of these techniques.⁴ Multiple studies evaluated the success rate and adverse effects of these endoscopic techniques. The use of stents allows early oral intake, provides immediate protection, and is easy to use. However, the stents can migrate and are challenging to use in lower GI fistulas. Two types of clips are used for fistula closure: Through-the-scope clip, reserved for smaller fistulas, and OTSC, which has a wider clip arm that allows the recruitment of more tissues with greater force. However, these clips require a robust mucosa, which is not always present in fistulas with friable tissue. Later, the development of suturing technology allowed the successful closure of many GI fistulas. Suturing permitted full-thickness plication and successful closure of larger fistulas that previous clips and stents could not close. However, it also requires the presence of robust mucosa, and it is technically challenging, especially in the proximal colon and small bowel.⁵

Tissue adhesives (fibrin glue, cyanoacrylate) also have been used to close GI fistulas. However, they have been associated with lower success rates, especially in high-output fistulas. When combined with other endoscopic techniques, a greater success rate is achieved. However, data are limited, and further research is warranted.^5,6 Emerging studies suggest that endoscopic vacuum therapy also could represent a potential treatment option for fistula closure. Nevertheless, investigations are predominantly confined to fistulas within the upper GI tract and those arising after surgical interventions. This technique necessitates recurrent endoscopic interventions and is accompanied by challenges such as sponge displacement and closure difficulties, particularly in cases in which the epithelium is fibrotic and tissue integrity is compromised.⁷

Despite all these contemporary management strategies, fistula closure remains challenging when tissue is friable and defects are large. The presence of a large defect with fragile surrounding tissue hinders effective closure, as traditional techniques struggle to securely grasp the tissue, increasing the risk of damage and failure. These fistulas can present as highly incapacitating adverse events with substantial morbidity and mortality. Thus, our case series introduces a new technique that offers an encouraging solution. This novel method proves advantageous in allowing the grabbing of deep tissue samples, creating a robust mucosa that can allow traction, and providing enough tissue to deploy the clip on. This innovative technique successfully treated the fistulas that could not be managed using traditional techniques because of the friability of the tissue, as any attempt at traction risks tissue damage and precludes successful fistula closure. Like any other invasive endoscopic procedure, this technique could carry potential pitfalls, although none were encountered in our cases. These include failure of tissue to pull into the cap as the result of fibrosis or large amounts of tissue captured in sutures, technical difficulty because of the possible need for help from one or multiple assistances in pulling multiple sutures at once, and failure of tissue granulation, which is a general limitation to any endoscopic closure technique, albeit less likely with our proposed technique.

Conclusions

In this case series, we present a novel technique that uses a suturing device to obtain full-thickness bites, enabling traction of the mucosa and facilitating the formation of a flap with sufficient tissue for clip deployment. This creates a promising solution for hard-to-treat fistulas that could not be managed using standard endoscopic techniques.

Disclosures

The authors declare no grants or financial support for the research, authorship, and publication of this article.

Supplementary data

Video 1

Ex vivo video demonstration of a novel endoscopic technique for fistula closure.

Video 2

Demonstrated in the video is our novel endoscopic technique used for fistula closure of hard-to-treat fistulas in 3 different cases.