Endoscopic closure of a gastrocolic fistula using the over-the-scope-clip-system

Figure 1 Billroth II anatomy. A clean-based ulcer is present at the anastomosis (A), the lumen to both the afferent and efferent limbs is patent (A); the gastrocolic fistula opening was located at the upper end of the anastomosis (B).

Figure 2 Insertion of the scope through this orifice lead to the colon (A), after placing the jejunostomy, water soluble contrast was injected confirming its perfect intra-jejunal position (B).

Figure 3 Before closing the fistula the entrance into the orifice was marked with India ink.

Figure 4 T the over-the-scope-clip -system come loaded onto a transparent cap which is attached to the tip of the scope.

Figure 5 The over-the-scope-clip-system was approximated to the fistula (A) and the proximal edge of the fistula was pulled inside the transparent cap of the over-the-scope-clip-system using the Twin Grasper (B).

Figure 6 Once enough tissue was present inside the cap the over-the-scope-clip device was released. (A) Example of deployed over-the-scope-clip -system in experimental perforation in an ex-vivo pig stomach (B).

Figure 7 Radiologic view of the over-the-scope-clip -system (‘‘bear trap”).

Figure 8 Barium study documents complete closure of the fistula. The contrast flows into the jejunal limbs.