Malignant duodenocolic fistula successfully treated with self-expandable partially covered metal stent and endoscopic suturing

Duodenocolic fistula is a rare complication of right-sided colon cancer and its management can be challenging because of surgery-related morbidity, especially in fragile patients in a palliative care setting [1]. Endoscopic treatment with self-expandable metal stents (SEMSs) is still a feasible and safe option in patients with poor performance status, but the risk of stent migration is not negligible [2].

We describe a case of an 83-year-old man affected by incurable colon cancer, who presented with weight loss, abdominal pain and diarrhea. Computed tomography (CT) and a subsequent fluoroscopic contrast study showed passage of contrast medium from the duodenum directly to the hepatic flexure of the colon ([Fig. 1]). Upper endoscopy revealed a large infiltrating, non-stenosing lesion in the wall of the proximal duodenum, fistulizing with the ascending colon ([Fig. 2]). We decided upon an endoscopic treatment: a through-the-scope clip was placed in the distal duodenum as a radiopaque marker, and a partially covered SEMS, 120 mm in length, was deployed ([Video 1]). We then placed an overtube to safely introduce the suturing device (OverStitch; Apollo Endosurgery, Austin, Texas, US) attached to the tip of a double-channel endoscope (GIF-2TH180, Olympus, Tokyo, Japan), in order to fix the proximal side of the stent to the gastric wall ([Fig. 3]). The procedure was uncomplicated and the patient resumed a soft diet after 24 hours. After 3 days the patient was discharged, and a regular oral intake was maintained until he died 4 months later because of disease progression.

Fig. 1 Malignant duodenocolic fistula in an 83-year-old man. Fluoroscopic contrast study showing the passage of contrast medium from duodenum to ascending colon.

Fig. 2 Endoscopic appearance of the duodenocolic fistula.

Video 1 Single-session treatment of a malignant duodenocolic fistula with stent deployment and endoscopic suturing.

Fig. 3 Stent deployed and sutured to the gastric wall.

In patients with malignant fistula, a covered SEMS is mandatory in order to restore the integrity of gastrointestinal wall, but the migration rate is still high, ranging from 6.5 % to 32.3 % [3]. The risk of migration is even greater when a fistula develops without a significant stricture. Endoscopic suturing devices can thus represent a useful tool, reducing the risk of stent migration and related complications within a single-session procedure [4] [5].

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• References

• 1 Gupta V, Kurdia KC, Kumar P. et al. Malignant colo-duodenal fistula: management based on proposed classification. Updates Surg 2018; 70: 449-458
• 2 Jue TL, Storm AC. ASGE Standards of Practice Committee. et al. ASGE guideline on the role of endoscopy in the management of benign and malignant gastroduodenal obstruction. Gastrointest Endosc 2021; 93: 309-322
• 3 Hori Y, Hayashi K, Naitoh I. et al. A pilot study of novel duodenal covered self-expandable metal stent fixation. Sci Rep 2021; 11: 19708
• 4 Granata A, Martino A, Ligresti D. et al. Closure techniques in exposed endoscopic full-thickness resection: overview and future perspectives in the endoscopic suturing era. World J Gastrointest Surg 2021; 13: 645-654
• 5 Ngamruengphong S, Sharaiha RZ, Sethi A. et al. Endoscopic suturing for the prevention of stent migration in benign upper gastrointestinal conditions: a comparative multicenter study. Endoscopy 2016; 48: 802-808