Endoscopic Assisted Laparoscopic Transgastric Division of a Gastroesophageal Fistula in an Adolescent

This video describes division of a gastroesophageal fistula in a 16 year old female with a history of prior Nissen fundoplication and gastrostomy tube placement as an infant. She presented to our clinic with progressive dysphagia and epigastric pain over a 2 month period. Initial attempts were made to divide the stapler using only a 12mm transgastric port at the prior gastrostomy site for the stapling device and an endoscope for visualization. Ultimately division required placement of an additional 5mm transgastric port for a laparoscope. Using both endoscopic and laparscopic visualization, the fistula was able to be divided using a standard laparoscopic stapler. At the completion of the procedure, the 5mm gastrotomy was closed and a gastrostomy tube was placed at the 12mm trocar site, which was then removed 2 months later. The patient’s dypshagia improved after the procedure and her gastrostomy tube site closed without event.

Endoscopically assisted laparoscopic division of a gastroesophageal fistula in an adolescent
Benign gastroesophageal fistula
Concern for malignancy Inability to safely place transgastric trocar Inability to perform endosopy
Supine positioning allowing for upper endocsopy; trocar placement typical for laparoscopic gastrostomy tube
Upper Gastrointestinal Series Upper endoscopy +/- biopsy if concern for malignancy
Endoscopy/Laparoscopic Identification of fistua and identification of tract during division
Advantages -Improved visualization -Decreased post-operative pain -Improved cosmesis Disadvantages -Dual imaging requirement -Coordination of visualization
Risks -Gastric leak/requirement of gastrostomy tube -Gastric/esophageal perforation
John Stroud and Paul Twomey-Erlanger AV department for their assistance in production

Review Endoscopic Assisted Laparoscopic Transgastric Division of a Gastroesophageal Fistula in an Adolescent.

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