P4511 - Closing Paths: ASD Occluder Innovation in Gastropleural Fistula Closure

Bryant Le, MD¹, Momin Masroor, MD², Nabil El Hage Chehade, MD³, Amirali Tavangar, MD², Joshua Kwon, MD¹, Peter H. Nguyen, MD², Jason Samarasena, MD², John G. Lee, MD², Frances Dang, MD^2
1University of California Irvine, Orange, CA; ²University of California, Irvine, Orange, CA; ³Scripps Clinic, San Diego, CA

Introduction: Gastropleural fistulas are characterized by an abnormal connection between the stomach and pleural space commonly due to trauma, diaphragmatic hernias, and malignancy. Although primarily designed for Atrial septal defects (ASDs), ASD occluders has been used successfully in closing tracheoesophageal and choledochoduodenal fistulas. Here, we describe a unique case of an ASD occluder used to close a gastropleural fistula when other conventional endoscopic methods were unsuccessful.

Case Description/Methods: A 29-year-old male presented after a gunshot wound with multiple abdominal injuries. He underwent left lower lobe lobectomy, transverse colectomy, and wedge gastrectomy amongst others. He also had a GE junction perforation due to wedge gastrectomy, treated with esophageal stent placement, endovac placement and removal, but with a persistent GE junction leak. An EGD revealed a large perforation at 46 cm from the incisors at the GEJ with contrast showing flow into the pleural space that was not anatomically approachable for clipping. EGD was performed again, now using an ASD occluder (waist diameter 7 mm) device over the guidewire under fluoroscopic guidance. Despite appearing in adequate position, a persistent leak was noted upon contrast injection. This ASD occluder was replaced by a larger one (26 mm) (Image A). Although the gastric flange disc appeared to flatten completely, the pleural flange disc was not completely flattened on fluoroscopy (possibly due to the large disc size of 40mm). Therefore, a persistent leak was noted after contrast injection (Image B). To improve the seal, 4 ml of fibrin glue was applied to the fistula. An upper GI series three days after device deployment showed no contrast leak (Image C). The patient advanced his diet slowly and his chest tube was later removed.

Discussion: The use of the ASD occluder in unconventional settings, such as closing non-septal cardiovascular defects or fistulas, highlights its versatility beyond its intended purpose. Successful closure of gastrointestinal fistulas using cardiac septal occluders (CSO) has been described in multiple cases. Selecting the right occluder size was a challenge and the defect required occluder replacement. Use of fibrin glue likely assisted with growth of granulation tissue. ASD occluders should be considered for refractory cases of gastrointestinal fistulas.




Disclosures:


Bryant Le, MD¹, Momin Masroor, MD², Nabil El Hage Chehade, MD³, Amirali Tavangar, MD², Joshua Kwon, MD¹, Peter H. Nguyen, MD², Jason Samarasena, MD², John G. Lee, MD², Frances Dang, MD². P4511 - Closing Paths: ASD Occluder Innovation in Gastropleural Fistula Closure, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.