Purse-string suture and double percutaneous endoscopic gastrostomies for treating a postoperative duodenal fistula

A 43-year-old woman was referred to our department owing to uncontained duodenal leak, drained from the retroperitoneal space (> 500 mL/24 h) ([Fig. 1]). Her medical history was significant for laparoscopic right nephrectomy owing to calculous pyonephrosis 7 days earlier. The patient refused surgery; thus, endoscopic intervention was performed ([Video 1]).

Fig. 1 The duodenal fistula (arrow) was demonstrated on abdominal computed tomography.

Video 1 Purse-string suture and double percutaneous endoscopic gastrostomies for treating a postoperative duodenal fistula.

Upper endoscopy confirmed the presence of the fistula at the junction of the duodenal bulb and descending duodenum ([Fig. 2 a]). Successful closure of the defect was achieved using a purse-string suture after failed attempts with endoclips ([Fig. 2 b]). We then carried out double percutaneous endoscopic gastrostomies (PEG) ([Fig. 2 c]). One PEG with placement of a jejunal feeding tube was for enteral nutrition, whereas the other was connected to the negative pressure drainage bag for gastric decompression and drainage. A nasointestinal decompression tube with string attached was placed near the fistula and fixed using an endoclip, for duodenal drainage. Conservative treatments were continued.

Fig. 2 Endoscopic images. a The fistula (arrow) at the junction between the bulb and descending part of the duodenum was confirmed by upper endoscopy. b Closure of the fistula was conducted using a purse-string suture. c Double percutaneous endoscopic gastrostomies were performed for adequate drainage.

The output from the retroperitoneal drainage tube reduced gradually, and no liquid was noted after 1 month. A gastrointestinal contrast study demonstrated no leaks ([Fig. 3]). Repeat upper endoscopy also showed the healing of the duodenal fistula. The tubes were removed successively, and the patient resumed oral intake. During 9 months of follow-up, no abnormalities were reported.

Fig. 3 No leak of contrast agent was noted on gastrointestinal imaging after 1 month.

Duodenal fistulas are the most difficult to repair, and invasive surgical intervention remains the main treatment, especially for those with uncontained leaks [1]. Although many endoscopic techniques, including clipping and purse-string suture, have been used to close intraoperative perforations [2] [3], duodenal fistulas closed by these methods may recur [1]. Fistula recurrence may be attributed to collected digestive juice, which harms the closed fistula and surrounding tissue. The current case demonstrated a method for adequate drainage of the stomach and the duodenum, to minimize additional contamination and injury. In addition, adequate nutritional support is also important for the healing of a duodenal fistula.

Endoscopy_UCTN_Code_TTT_1AO_2AI

^* These authors contributed equally to this work.

• References

• 1 Muniraj T, Aslanian HR. The use of OverStitch™ for the treatment of intestinal perforation, fistulas and leaks. Gastrointest Interv 2017; 6: 151-156
• 2 Rustagi T, McCarty TR, Aslanian HR. Endoscopic treatment of gastrointestinal perforations, leaks, and fistulae. J Clin Gastroenterol 2015; 49: 804-809
• 3 Li Q, Ji J, Wang F. et al. ERCP-induced duodenal perforation successfully treated with endoscopic purse-string suture: a case report. Oncotarget 2015; 6: 17847-17850