LAUSR

A gastro-gastric fistula is a rare but wellknown complication of Roux-en-Y gastric bypass surgery, which can lead to weight regain and ulceration [1]. Most commonly, surgical approaches are used to repair such defects [2]; however, endoscopic repair methods have also been used with various success rates [3]. We report the first case of the endoscopic closure of multiple gastro-gastric fistulas in a single session, using an X-Tack Endoscopic HeliX Tacking System (Apollo Endosurgery, Inc., Austin, Texas, USA). A 34-year-old man presented with upper abdominal pain, accompanied by weight loss of 70 kgs during the 12 months since he had undergone bariatric surgery. The patient had a history of laparoscopic adjustable gastric band surgery, which had been converted to a mini-gastric bypass after he had regained his presurgery weight. Index endoscopy revealed a 4-cm gastric pouch, with two gastro-gastric fistulas between the gastric pouch and the excluded gastric remnant, onemeasuring 12mm and the other 8mm (▶Fig. 1 a). Each fistula was cauterized using argon plasma coagulation (APC) to remove the mucosa and encourage healing fibrosis. The X-Tack Endoscopic HeliX Tacking device was then used with 12 helices, along with prolene 2–0 sutures, to close both fistulas, which were covered with a layer of normal mucosa (▶Fig. 1 b). As shown in ▶Video 1, no visible tract was noted at the conclusion of the procedure and a patent anastomosis was retained. A computed tomography scan was performed 2 months later, which showed no extravasation of oral contrast material from the gastric pouch to the excluded gastric remnant, indicating durable closure of the fistulas. The patient currently remains pain free and has started to gain weight since the procedure.