Endoscopy 2020; 52(01): E31-E32
DOI: 10.1055/a-0978-4760
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© Georg Thieme Verlag KG Stuttgart · New York

How to endoscopically repair a biliodigestive fistula complicating a perforated peptic ulcer: a customized “natural” choledochoduodenal anastomosis

Laurent Monino
1  Department of Hepatogastroenterology, Université catholique de Louvain, Cliniques universitaires Saint-Luc, Brussels, Belgium
2  Department of Hepatogastroenterology, Assistance Publique des Hôpitaux de Marseille, Aix-Marseille Université, Hôpital Nord, Marseille, France
,
Jean-Michel Gonzalez
2  Department of Hepatogastroenterology, Assistance Publique des Hôpitaux de Marseille, Aix-Marseille Université, Hôpital Nord, Marseille, France
,
Marc Barthet
2  Department of Hepatogastroenterology, Assistance Publique des Hôpitaux de Marseille, Aix-Marseille Université, Hôpital Nord, Marseille, France
› Author Affiliations
Further Information

Corresponding author

Laurent Monino, MD
Department of Hepatogastroenterology
AP-HM, Aix-Marseille Université, Hôpital Nord
Chemin des Bourrely
13015 Marseille
France   
Fax: +33-4-91968737   

Publication History

Publication Date:
21 August 2019 (online)

 

A perforated peptic ulcer is associated with a 30 % mortality and 50 % morbidity and is usually managed as a surgical emergency [1]. To seal the perforation, applying interrupted sutures with omental apposition is the most commonly used technique [2]. In a few cases, a perforated peptic ulcer may be complicated by a choledochoduodenal fistula, which is managed surgically by laparoscopic digestive resection [3] or medically with a protein pump inhibitor and endoscopic retrograde cholangiopancreatography (ERCP). We present a case of a biliary fistula complicating a perforated peptic ulcer that was managed endoscopically in an original way.

An 84-year-old man presented with abdominal pain and fever. Clinical results showed an inflammatory syndrome associated with normal findings from hepatic tests. A perforated peptic ulcer was confirmed by computed tomography (CT) and antibiotic therapy was started (piperacillin/tazobactam 12 g daily). The patient had emergency surgery with suturing and abdominal drainage. The drain started producing biliary fluid 1 week later at a volume of 300 to 500 mL/day. At 1 month, imaging confirmed a persistent duodenal leak, and the patient was transferred to our tertiary center.

Endoscopically, we found an ulcer located in the bulb in contact with the surgical drain hiding the choledochoduodenal fistula ([Fig. 1 a], [Video 1]). First, a straight catheter with a guidewire was introduced into the choledochoduodenal fistula and opacification allowed visualization of the biliary tree ([Fig. 1 b]). Second, a fully covered metal biliary stent was deployed, with the proximal flange in the common bile duct and the distal flange in the stomach, to channel the biliary flow. Third, an enteral metallic fully covered stent was deployed that covered the bulb ulcer ([Fig. 2]). There was no perioperative complication. At day 1, no biliary fluid persisted in the drain, which was removed. At 6 weeks, an endoscopic control showed after stent removal a complete cicatrization of the bulb ([Fig. 3 a]) with a “natural” choledochoduodenal anastomosis ([Fig. 3 b]).

Zoom Image
Fig. 1 A perforated peptic ulcer complicated by a leaking choledochoduodenal fistula. a Biliary fistula opening. b A perforated peptic ulcer with biliary leak.

Video 1 Endoscopic repair of biliodigestive fistula complicating a perforated peptic ulcer, providing a customized “natural” choledochoduodenal anastomosis.


Quality:
Zoom Image
Fig. 2 Endoscopic treatment with multiple prostheses.
Zoom Image
Fig. 3 Control of endoscopic treatment at 6 weeks. a Choledochoduodenal anastomosis lumen. b Fluoroscopic control showing a customized “natural” choledochoduodenal anastomosis.

This case illustrates the possibilities of therapeutic endoscopy to treat complex biliary fistulas by directing the bile towards the digestive tract.

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Competing interests

None


Corresponding author

Laurent Monino, MD
Department of Hepatogastroenterology
AP-HM, Aix-Marseille Université, Hôpital Nord
Chemin des Bourrely
13015 Marseille
France   
Fax: +33-4-91968737   


Zoom Image
Fig. 1 A perforated peptic ulcer complicated by a leaking choledochoduodenal fistula. a Biliary fistula opening. b A perforated peptic ulcer with biliary leak.
Zoom Image
Fig. 2 Endoscopic treatment with multiple prostheses.
Zoom Image
Fig. 3 Control of endoscopic treatment at 6 weeks. a Choledochoduodenal anastomosis lumen. b Fluoroscopic control showing a customized “natural” choledochoduodenal anastomosis.