ENDOSCOPIC MANAGEMENT OF GASTROCOLIC FISTULA AFTER EUS-GUIDED GASTROJEJUNUOSTOMY (EUS-GJ)

Aims:

EUS-GJ with lumen apposing metallic stents (LAMS) is a technique to create a fistula between the stomach and the jejunum, to relieve symptoms in case of gastric outlet obstruction (GOO). One of the most feared complications is accidental deployment into the colon. We describe a case with delayed stent migration from the small intestine to the transverse colon after EUS-GJ which was managed endoscopically.

Methods:

The patient is a 78-year-old male with an inoperable slowly growing metastatic carcinoid tumor measuring 6 cm near the head of the pancreas who developed symptoms of GOO. He was initially treated with EUS-GJ with good clinical effect, but after three weeks he complained of diarrhea after food intake. He also developed severe malnutrition and dehydration. On follow-up, we found that the distal flange of the LAMS had eroded into the colon to form a gastro-colostomy, confirmed by a trans-gastric colonoscopy. There was also reflux of colonic content to the esophagus.

We rinsed the stomach and colon for content and cleaned with acetic acid as an antiseptic. The LAMS was removed with a snare. The fistula opening was then closed with full thickness sutures using an endoscopic suturing device (OverStich, Apollo endosurgery). Afterwards we installed contrast in the stomach but saw no more leakage to the colon. A temporal naso-enteral tube used to improve the nutritional state.

Results:

After two weeks, we performed successfully a new EUS-GJ. The previous gastrocolic fistula had closed. The patient could start oral nutrition, and was discharged after 5 days.

Conclusions:

Even though a gastrocolic fistula is a serious complication of EUS-GJ, it can be managed endoscopically.