We present a case of a 55-year-old woman with metastatic multi-focal breast cancer
and retroperitoneal leiomyosarcoma who developed gastric outlet obstruction secondary
to extrinsic compression from a spinal fixation cage. Cross sectional imaging confirmed
the presence of a duodenal fistula which had led to the formation of a spinal collection.
The patient was not deemed to be a surgical candidate and was referred for endoscopic
management. Following Multidisciplinary team discussion, a fully covered self-expanding
metal stent (FCSEM) in the duodenum to cover the fistula however repeat imaging revealed
an enlarging collection alongside clinical deterioration with worsening neurology
and elevated inflammatory markers. A second overlapping FCSEM to further extend the
coverage of the primary duodenal stent was unsuccessful in preventing ongoing leak.
An EUS-guided gastrojejunostomy (EUS-GJ) was successfully performed to bypass the
defect. Unfortunately, the patient remained pyrexial and barium follow through study
revealed contrast flowing into the duodenum and an ongoing leak. To divert gastric
contents into the gastrojejunostomy we performed a pyloric exclusion with the Apollo
Overstitch NXT device. Four overlapping and interrupted sutures were deployed to close
the pylorus. This was confirmed endoscopically. Following pyloric exclusion, the patient
demonstrated improvement in her inflammatory markers and was subsequently started
on a soft oral diet. Endoscopic pyloric exclusion alongside EUS-GJ is a technically
feasible and potentially reversible novel procedure in patients with duodenal defects
where endoscopic options have failed and/or surgical options are limited.
