V5 - Endoscopic Management of a Complex Gastrocolojejunal (GCJ) Fistula Following EUS-GJ

Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) has emerged as a minimally invasive treatment for gastric outlet obstruction, but adverse events including misdeployment can occur with significant morbidity, potentially requiring surgical intervention. We present a case of complex gastrocolojejunal (GCJ) fistula after EUS-GE successfully managed using advanced endoscopic closure techniques.

Case Description/

Methods:

A 69-year-old male with acute necrotizing pancreatitis following renal cell carcinoma resection developed gastric outlet obstruction requiring EUS-GE. An EUS-GE was created with difficulty using a 15×10mm electrocautery-enhanced lumen-apposing metal stent (LAMS) by the freehand technique. Eight weeks post-procedure, the patient presented with septic shock and suspected anastomotic leak. Endoscopic evaluation revealed a 10mm gastrocolic fistula with an additional 10mm colojejunal fistula, creating a complex GCJ communication. Two telescoping LAMS with a coaxial fully covered metal stent (22x100mm) were initially placed to bridge the fistula tracts. Given the patient's poor surgical candidacy, definitive endoscopic repair was pursued after multidisciplinary consensus.

On repeat endoscopy, the previously placed stents were removed using grasping forceps. Using a double-channel gastroscope mounted with an over-the-scope suturing device (OverStitch; Boston Scientific, MA), the colojejunal fistula was accessed through the gastrocolic tract. The defect was closed by a running 2.0 polypropylene sutures to achieve primary closure. The closure site was further reinforced with a 12×6mm, type T, over-the-scope clip (OTSC, Ovesco Endoscopy). Subsequently, the endoscope was withdrawn to the stomach and the gastrocolic fistula was repaired by a 2.0 polypropylene running suture and OTSC reinforcement, in similar fashion. Real-time fluoroscopy with contrast injection confirmed complete seal without extravasation. Follow-up endoscopy in one week demonstrated intact closure with no evidence of leak or dehiscence. The patient recovered without further adverse events.

Discussion:

This case demonstrates the feasibility and effectiveness of advanced endoscopic suturing combined with clip reinforcement for managing complex multi-tract fistulas following a misdeployed EUS-GE stent. The combination of primary suture closure and OTSC reinforcement provides durable repair, offering a viable alternative to high-risk surgery in critically-ill patients with extensive comorbidities.