Complex duodenal fistula successfully treated with EUS guided gastrojejunostomy and pyloric exclusion

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.

Publication History

Article published online:
27 March 2025