Treatment of gastropleural fistula with combined endoscopic therapy: endoscopic vacuum therapy and over-the-scope clip

Background and Aims: Gastropleural fistulas (GPFs) are rare pathologic communications between the stomach and the pleural cavity and are associated with high morbidity and limited success with conventional surgical repair. We aimed to describe the successful management of a complex, refractory GPF using a multimodal endoscopic approach. Methods: A 27-year-old man with traumatic diaphragmatic rupture and multiple failed surgical repairs was referred to our tertiary endoscopy center. Endoscopic evaluation confirmed a gastric-to-pleural fistula. A sequential strategy was used: initial endoscopic negative pressure therapy using a modified nasogastric vacuum system, followed by closure with an over-the-scope (OTS) clip. Results: Negative pressure therapy promoted granulation tissue formation and reduction of fistula output. Deployment of an OTS clip achieved complete sealing of the orifice, with no further thoracic drainage. Total endoscopic therapy lasted 28 days. The patient was discharged in good clinical condition. At 6-month follow-up, he remained asymptomatic, with endoscopy confirming a well-healed scar and no recurrence. Conclusions: Multimodal endoscopic therapy combining negative pressure therapy and OTS clip placement represents a safe and minimally invasive option for complex GPFs refractory to surgery. This case highlights the growing role of advanced endoscopic techniques in the management of challenging gastrointestinal fistulas.