Gastrocolonic malignant fistulas can occur, although rarely, complicating gastric
or colonic neoplasms. En bloc resection of the fistulous tract and involved segments
is the first-line treatment whenever possible, with endoscopic treatment an alternative.
Endoscopic closure has been described using covered stents [1]
[2], over-the-scope clips [3], and atrial septal defect occlusion devices [4]. However, in the colon, covered stents are associated with a high migration risk
[5].
We therefore developed a new technique to allow fistula closure, overcoming the risks
of stent migration by initially placing an uncovered stent, which is followed by the
deployment of a covered stent inside the first stent a few days later and fixation
of the two stents to each other using through-the-scope clips.
Our patient, a 58-year-old woman, had a metastatic and locally advanced intestinal-type
gastric cancer with colonic invasion. After receiving 12 cycles of palliative chemotherapy,
she was admitted with fecaloid emesis and a computed tomography (CT) scan showed a
large fistulous tract (approximately 5 cm in length with a large orifice) between
the stomach and the transverse colon. Although the patient had a good performance
status, surgical resection was not considered feasible and endoscopic palliation was
proposed.
Esophagogastroduodenoscopy (EGD) showed a large ulcerated neoplasm in the greater
curvature of the gastric antrum, with a large orifice communicating with an ulcerated
fistulous tract. Colonoscopy revealed a stenosis in the transverse colon and contrast
instillation allowed characterization of the stricture and of the fistulous tract.
An uncovered metal stent (WallFlex; 22 – 27 mm × 90 mm; Boston Scientific, Marlborough,
Massachusetts, USA) was then placed in the strictured transverse colon where the colonic
fistulous orifice was located. After 3 days (to allow time for embedment of the uncovered
stent in the colonic wall), a similar caliber partially covered stent (Hanarostent;
26–20–26 mm × 90 mm; M. I. Tech, Pyeongtaek-si, Gyeonggi, South Korea) was deployed
inside the previously placed stent in order to occlude the fistulous tract. Finally,
the meshes of the two metal stents were fixed to each other with two metal clips ([Fig. 1]; [Video 1]).
Fig. 1 Endoscopic and fluoroscopic images showing a partially covered stent that was placed
inside a previously deployed uncovered colonic stent to provide endoscopic closure
of a large gastrocolonic fistulous tract.
Video 1: An uncovered colonic stent was initially placed through the stricture at
the orifice of the gastrocolonic fistula. After 3 days, which allowed time for the
stent to embed in the colonic wall, a partially covered stent was deployed inside
the first one and to avoid migration the stents were attached to each other using
metal clips.
This innovative approach allowed the fistulous tract to be closed, as seen in a gastroduodenal
series performed after 3 days, and the patient was discharged 3 days later on an oral
diet. Closure of the fistula allowed the patient’s palliative chemotherapy to be continued
and 6 months later she was still alive, without any fistula-related symptoms and with
the stents in place. We believe that this technique should be considered to decrease
the risk of migration whenever an enteral covered stent is needed to occlude a fistulous
tract or dehiscence.
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