Duodenal fistula is a rare but serious complication of gastrointestinal surgery, abdominal
trauma, and iatrogenic procedures in general [1]. It is most commonly seen in critically ill patients at elevated risk of death,
and its treatment is associated with great challenges, including repeated episodes
of recurrence [2]. Endoscopic closure methods are now becoming more reliable and are already being
considered as first-line options in the management of this condition.
A 61-year-old man underwent ileocolectomy due to complicated appendicitis. He was
referred to our institution and underwent a new procedure because of dehiscence of
the ileocolic anastomosis. A new ileocolic anastomosis was performed. After a few
days, the presence of a duodenal cutaneous fistula associated with a large peritoneal
collection became evident. The peritoneal collection was surgically drained, but the
duodenal leak persisted.
The patient underwent an endoscopic closure attempt, performed with standard through-the-scope
clips (TTSC). The procedure was unsuccessful, and the fistula showed signs of recanalization
([Fig. 1]). A second endoscopic procedure was performed, using the Amplatzer septal occluder
(St. Jude Medical, St. Paul, Minnesota, USA). The Amplatzer is a self-expandable,
double-disk occluder device developed for the endovascular treatment of persistent
cardiac wall defects [3]. We fashioned an endoscopic introduction device using the external sheath of a 12-Fr
biliary plastic stent and a pediatric biopsy forceps ([Video 1]; [Fig. 2]). The opening of the first flange was performed under fluoroscopic guidance, while
the second flange (in the duodenal lumen) was deployed under endoscopic surveillance
([Fig. 3]). Control fluoroscopy showed no contrast leak. After the procedure, the patient
showed decreasing amounts of leakage through the external orifice of the fistula,
received oral diet, and after 12 days was discharged. Endoscopic follow-up 7 months
later showed the occluder in situ, partially grown into by the surrounding mucosa
([Fig. 4]). No recurrences were documented during this period.
Fig. 1 Endoscopic view of a duodenal cutaneous fistula in a 61-year-old man.
Video 1 Successful treatment of a persistent duodenal fistula using the Amplatzer septal
occluder.
Fig. 2 Endoscopic introduction device fashioned by the present authors.
Fig. 3 Endoscopic view of the deployed Amplatzer septal occluder.
Fig. 4 Endoscopic view at follow-up 7 months after the procedure.
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
