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
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high quality video and all
contributions are freely accessible online.
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