PMC3123845_01
Upright posteroanterior chest radiograph: there is free subdiaphragmatic air bilaterally that is more clearly noted on the left side (white arrows).
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fig1
Upright chest X-ray demonstrated free subdiaphragmatic air bilaterally (Figure 1).
The cutaneous orifice of the fistula discharging gastric juice.
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fig2
The immediate postoperative period was uneventful with the exception of a persistent draining of gastric contents by the abdominal drains (Figure 2).
Upper GI study with gastrografin showing a gastrocutaneous fistula (arrow).
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fig3
A high-output gastrocutaneous fistula from the lesser curvature was documented on upper gastrointestinal (GI) series with gastrografin (Figure 3), and an upper GI endoscopy revealed the presence of an orifice at the anterior gastric wall located towards the lesser curvature, between the gastric body and the antrum.
The OTSC system.
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fig4
Finally, the endoscopic treatment of the fistula was decided using the "traumatic type" OTSC system for the closure of the gastric orifice (Figure 4), and a written informed consent from the patient and the approval by the hospital's medical scientific committee were obtained for this purpose.
The gastric orifice of the gastrocutaneous fistula (arrow) during endoscopic application of the OTSC device.
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fig5
The gastric orifice of the fistula was recognized (Figure 5), the tip of endoscope was adapted to the lesion, and additional tissue retraction was obtained by means of the OTSC twin-grasper.
Immediate postinterventional endoscopic view. The tissue at the gastric orifice was captured with OTSC, and the fistula orifice was successfully sealed (arrow).
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fig6
Finally, the orifice and the surrounding tissue that were successfully captured within clip jaws and teeth (Figure 6).
Upper GI study with gastrografin 48 hours after procedure, showing the gastric OTSC in place (arrows) without leaks of contrast media.
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fig7
Upper GI studies with gastrografin (Figure 7) and endoscopy 48 hours after the OTSC placement confirmed the fistula's closure.
Postinterventional followup after 6 weeks. The cutaneous orifice was completely healed.
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fig8
The postprocedure period was uneventful, the patient was switched to oral diet, and the cutaneous orifice of the fistula was completely healed 2 weeks later (Figure 8).
Postinterventional followup after 6 weeks. Endoscopic view of the OTSC in situ with gastric fistula orifice closure (arrow).
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fig9
Six weeks after the application of OTSC, upper GI studies with gastrografin swallow (Figure 9) and endoscopy (Figure 10) ruled out any evidence of fistula's persistence or relapse, while the OTSC device was still in place.
Postinterventional followup after 6 weeks. Gastrografin upper GI study showing the gastric OTSC in place (arrow) without leaks of contrast media.
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fig10
Six weeks after the application of OTSC, upper GI studies with gastrografin swallow (Figure 9) and endoscopy (Figure 10) ruled out any evidence of fistula's persistence or relapse, while the OTSC device was still in place.