Successful closure of a duodenal stump leak with an over-the-scope clip using double-balloon endoscope

A 62-year-old man with a history of distal gastrectomy and Billroth I reconstruction for gastric cancer was diagnosed with early gastric cancer in the remnant stomach, necessitating endoscopic submucosal dissection. On postoperative day 1, the patient experienced sudden-onset abdominal pain. Computed tomography (CT) demonstrated free air and mediastinitis, indicating a delayed perforation. Total gastrectomy with Roux-en-Y reconstruction, irrigation, and drainage was subsequently performed.

On postoperative day 5, bloody discharge was observed coming from the drain. On postoperative day 6, double-balloon endoscopy revealed two duodenal stump leaks measuring approximately 4 mm and 3 mm, respectively, with brisk bleeding in one of them ([Fig. 1], [Fig. 2]). Repeat CT identified the gastroduodenal artery as the source of bleeding ([Fig. 3]), and arteriogram coil embolization successfully achieved hemostasis. Considering that fistulas could cause intra-abdominal rebleeding or intra-abdominal abscesses, closure using over-the-scope (OTS) clips was planned. However, the diameter of the double-balloon endoscope tip was smaller than that of compatible OTS clips, complicating the mounting process. To address this, vinyl tape was wrapped around the scope tip several times to increase its outer diameter, enabling OTS clip mounting onto the scope ([Fig. 4], [Video 1]). This facilitated successful fistula closure using OTS clips ([Fig. 5]), significantly improving the patient’s condition without complications or recurrent leaks.

Fig. 1 Endoscopic image demonstrating two duodenal stump fistulas measuring approximately 4 mm and 3 mm in diameter, respectively.

Fig. 2 Fluoroscopic endoscopy showing contrast agent leaking outside the duodenal stump (yellow arrowheads).

Fig. 3 Contrast-enhanced computed tomography showing extravasation from the gastroduodenal artery (yellow arrowheads).

Fig. 4 The over-the-scope clip was mounted onto the tip of the double-balloon endoscope.

Fig. 5 Successful closure of the duodenal stump leak was achieved.

We wrapped vinyl tape around the scope tip several times to increase the outer diameter, making it possible to mount the over-the-scope clip onto the double-balloon endoscope.Video 1

OTS clips are a novel endoscopic modality used to close gastrointestinal defects [1] [2]. Duodenal stump leakage is a serious post-gastrectomy complication [3], and endoscopic treatment is technically challenging in patients who have undergone Roux-en-Y reconstruction [4]. This case highlights the significant therapeutic potential of OTS clips with a double-balloon endoscope for closing fistulas, even in complex postoperative reconstructions.

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Conflict of Interest

The authors declare that they have no conflict of interest.

Acknowledgement

We thank Hideki Kobara for careful advice on this case report.

• References

• 1 Kobara H, Mori H, Fujihara S. et al. Outcomes of gastrointestinal defect closure with an over-the-scope clip system in a multicenter experience: an analysis of a successful suction method. World J Gastroenterol 2017; 23: 1645-1656
• 2 von Renteln D, Vassiliou MC, Rothstein RI. Randomized controlled trial comparing endoscopic clips and over-the-scope clips for closure of natural orifice transluminal endoscopic surgery gastrotomies. Endoscopy 2009; 41: 1056-1061
• 3 Gu L, Zhang K, Kang Z. et al. Risk factors for duodenal stump leakage after laparoscopic gastrectomy for gastric cancer. J Gastric Cancer 2020; 20: 81-94
• 4 Morano WF, Shaikh MF, Gleeson EM. et al. Reconstruction options following pancreaticoduodenectomy after Roux-en-Y gastric bypass: a systematic review. World J Surg Oncol 2018; 16: 168

Publication History

Article published online:
22 November 2024