Endoscopy 2019; 51(03): E55-E56
DOI: 10.1055/a-0800-8286
E-Videos
© Georg Thieme Verlag KG Stuttgart · New York

Purse-string suture and double percutaneous endoscopic gastrostomies for treating a postoperative duodenal fistula

Liansong Ye*
Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
,
Xianhui Zeng*
Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
,
Xianglei Yuan
Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
,
Linjie Guo
Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
,
Yuyan Zhang
Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
,
Yan Li
Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
,
Bing Hu
Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, China
› Author Affiliations
Further Information

Corresponding author

Bing Hu, MD
Department of Gastroenterology
West China Hospital
37 Guo Xue Alley
Wu Hou District
Chengdu City
Sichuan Province 610041
Fax: +86-28-85423387   

Publication History

Publication Date:
11 January 2019 (eFirst)

 

A 43-year-old woman was referred to our department owing to uncontained duodenal leak, drained from the retroperitoneal space (> 500 mL/24 h) ([Fig. 1]). Her medical history was significant for laparoscopic right nephrectomy owing to calculous pyonephrosis 7 days earlier. The patient refused surgery; thus, endoscopic intervention was performed ([Video 1]).

Zoom Image
Fig. 1 The duodenal fistula (arrow) was demonstrated on abdominal computed tomography.

Video 1 Purse-string suture and double percutaneous endoscopic gastrostomies for treating a postoperative duodenal fistula.

Georg Thieme Verlag. Please enable Java Script to watch the video.

Upper endoscopy confirmed the presence of the fistula at the junction of the duodenal bulb and descending duodenum ([Fig. 2 a]). Successful closure of the defect was achieved using a purse-string suture after failed attempts with endoclips ([Fig. 2 b]). We then carried out double percutaneous endoscopic gastrostomies (PEG) ([Fig. 2 c]). One PEG with placement of a jejunal feeding tube was for enteral nutrition, whereas the other was connected to the negative pressure drainage bag for gastric decompression and drainage. A nasointestinal decompression tube with string attached was placed near the fistula and fixed using an endoclip, for duodenal drainage. Conservative treatments were continued.

Zoom Image
Fig. 2 Endoscopic images. a The fistula (arrow) at the junction between the bulb and descending part of the duodenum was confirmed by upper endoscopy. b Closure of the fistula was conducted using a purse-string suture. c Double percutaneous endoscopic gastrostomies were performed for adequate drainage.

The output from the retroperitoneal drainage tube reduced gradually, and no liquid was noted after 1 month. A gastrointestinal contrast study demonstrated no leaks ([Fig. 3]). Repeat upper endoscopy also showed the healing of the duodenal fistula. The tubes were removed successively, and the patient resumed oral intake. During 9 months of follow-up, no abnormalities were reported.

Zoom Image
Fig. 3 No leak of contrast agent was noted on gastrointestinal imaging after 1 month.

Duodenal fistulas are the most difficult to repair, and invasive surgical intervention remains the main treatment, especially for those with uncontained leaks [1]. Although many endoscopic techniques, including clipping and purse-string suture, have been used to close intraoperative perforations [2] [3], duodenal fistulas closed by these methods may recur [1]. Fistula recurrence may be attributed to collected digestive juice, which harms the closed fistula and surrounding tissue. The current case demonstrated a method for adequate drainage of the stomach and the duodenum, to minimize additional contamination and injury. In addition, adequate nutritional support is also important for the healing of a duodenal fistula.

Endoscopy_UCTN_Code_TTT_1AO_2AI

Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high quality video and all contributions are freely accessible online.
This section has its own submission website at https://mc.manuscriptcentral.com/e-videos


#

Competing interests

None

Acknowledgment

This study was funded by the National Key R&D Program of China (2017YFC0112300).

* These authors contributed equally to this work.



Corresponding author

Bing Hu, MD
Department of Gastroenterology
West China Hospital
37 Guo Xue Alley
Wu Hou District
Chengdu City
Sichuan Province 610041
Fax: +86-28-85423387   


Zoom Image
Fig. 1 The duodenal fistula (arrow) was demonstrated on abdominal computed tomography.
Zoom Image
Fig. 2 Endoscopic images. a The fistula (arrow) at the junction between the bulb and descending part of the duodenum was confirmed by upper endoscopy. b Closure of the fistula was conducted using a purse-string suture. c Double percutaneous endoscopic gastrostomies were performed for adequate drainage.
Zoom Image
Fig. 3 No leak of contrast agent was noted on gastrointestinal imaging after 1 month.