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Endoscopic repair of gatstrojejunocolic fistala using tandem stent placement with a long covered metal stent.
Abbreviations:
EUS-GJ (EUS-guided gastrojejunostomy), GCF (gastrocolonic fistulas), GOO (gastric outlet obstruction), LAMS (lumen-apposing metal stent)Introduction
Endoscopic ultrasound–guided gastrojejunostomy (EUS-GJ) is an alternative to endoscopic stent placement alone and surgical gastrojejunostomy for the management of gastric outlet obstruction (GOO). Similar technical and clinical success rates have been shown with EUS-GJ and endoscopic stent placement alone with lower rates of reintervention in the EUS-GJ group.
1
When compared to the more invasive surgical GJ, EUS-GJ has shown similar rates of clinical success and lower adverse event rates.2
,3
Rare EUS-GJ adverse events include perforation, peritonitis, bleeding, stent misdeployment, and migration.1
,4
The following case describes the formation of a gastrojejunocolic fistula as a rare delayed sequela of EUS-GJ.Case
A 52-year-old woman with a history of metastatic gastric cancer status after multiple lines of leucovorin calcium (folinic acid), fluorouracil, and oxaliplatin initially presented with GOO and underwent EUS-GJ via a 15-mm lumen-apposing metal stent (LAMS) anchored with a plastic stent (Fig. 1). She was discharged on a low-residue diet. One month later, she was readmitted with abdominal pain, distension, and new-onset diarrhea. Computer tomography showed progression of disease with interval development of large volume ascites without luminal obstruction. Abdominal pain improved after therapeutic paracentesis; however, diarrhea persisted. Repeat EGD noted migration of the LAMS with fistulization into both the adjacent jejunum and transverse colon (Fig. 2). The LAMS was removed and a new 20-mm LAMS was placed with the distal end in the jejunum (bypassing the gastrocolic fistula), anchored with a double-pigtail 7F × 10-cm plastic stent (Fig. 3). Flexible sigmodoscope visualized the gastrojejunocolic fistula (Fig. 4). The fistula was effectively bridged via the newly placed LAMS. Attempts to close the fistula from the colonic side via hemostatic clips were unsuccessful. Three interrupted sutures were placed via an endoscopic suturing device with good tissue approximation and fistula closure (Fig. 5).
Figure 1Initial gastrojejunostomy showing 15-mm lumen-apposing metal stent with distal end in the jejunum and the proximal end in the stomach (A). A 7F × 5-cm anchoring double-pigtail plastic stent within 15-mm lumen-apposing metal stent (B).
Figure 2Gastric body with lumen-apposing metal stent extending into the colon with adjacent fistula into the jejunum. Top arrow: colon; bottom arrow: small bowel.
Figure 3A 20-mm lumen-apposing metal stent anchored with a double stent in proximal end of gastric body and distal end in fistulized loop of small bowel bypassing the colon.
Figure 4A 10-mm fistula (to small bowel) with lumen-apposing metal stent traversing splenic flexure as seen on flexible sigmoidoscopy.
Figure 5Fistula after endoscopic suture repair.
The patient developed recurrent diarrhea within 1 week. Repeat EGD again noted proximal migration of the GJ stent into the fistulized colon resulting in a recurrent gastrojejunocolic conduit. A guidewire was introduced into the gastrojejunal fistula within the prior LAMS. A tandem 15-mm LAMS was placed with the distal end in the jejunum and the proximal end in the stomach. A 20-mm × 6-cm long covered stent was placed within tandem 15-mm and 20-mm LAMSs to create a longer gastrojejunal conduit (Figs. 6 and 7; Video 1, available online at www.giejournal.org). Diarrhea symptoms resolved postprocedure. Her malignancy continued to progress and she eventually died 1 month later.
Figure 6CT abdomen/pelvis coronal view (A) and fluoroscopic image (B) showing tandem stent placement with a long covered metal stent.
Figure 7A 20-mm × 6-cm long covered metal stent within tandem 15-mm and 20-mm lumen-apposing metal stents with the distal end in the jejunum and the proximal end within the stomach.
Discussion
Gastrojejunocolic fistulas can occur in the context of inflammatory disease processes, including malignancy. For gastrocolonic fistulas (GCFS) in particular, typical symptoms include abdominal pain, diarrhea, and weight loss.
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,6
Risk factors in this case include the inflammatory state of her widely metastatic malignancy as well as the development of large volume ascites leading to biomechanical tension on the LAMS itself.Closure of malignant GCFs can be challenging in these cases. Endoscopic interventions for repair include hemostatic clips, suturing, stent placement, and tissue adhesives. Endoclips can be effective in the immediate closure of benign GI fistulas, but long-term success rates are low.
7
Endoscopic suturing requires specialized technical expertise and can be effective for closing larger fistulas. One study noted a 62% clinical success rate for patients who underwent endoscopic suturing for repair of GI fistula; however, success was limited to patients who had early closure.8
To our knowledge, this case demonstrates the first reporting of a gastrojejunocolic fistula after EUS-GJ. There are numerous endoscopic tools readily available for fistula closure, but many have inherent limitations. Bridging malignant luminal fistulas with associated ascites can have high technical success rates but carry the risk of stent migration.
8
For the repair of gastrojejunocolic fistula following EUS-GJ, tandem stent placement with a long covered metal stent represents an effective rescue intervention.Disclosure
Dr Sharaiha is a consultant for Boston Scientific and Olympus. All other authors disclosed no financial relationships.
Supplementary data
- Video 1
Endoscopic repair of gatstrojejunocolic fistala using tandem stent placement with a long covered metal stent.
References
- EUS-guided gastroenterostomy is comparable to enteral stenting with fewer re-interventions in malignant gastric outlet obstruction.Surgical Endoscopy. 2017; 31: 2946-2952
- Safety and efficacy of fistula closure by endoscopic suturing: a multi-center study.Endoscopy. 2016; 48: 1023-1028
- Clinical outcomes of endoscopic ultrasound-guided gastroenterostomy for gastric outlet obstruction: a systematic review and meta-analysis.Minim Invasive Ther Allied Technol. 2022; 31: 159-167
- Endoscopic ultrasound-guided gastrojejunostomy with a lumen-apposing metal stent: a multicenter, international experience.Endosc Int Open. 2016; 4: E276-E281
- Gastrocolic fistulae; from Haller till nowadays.Int J Surg. 2012; 10: 129-133
- Gastrocolic fistulae in benign peptic ulcer disease.Ann Surg. 1976; 184: 236-240
- Endoscopic management of patients with post-surgical leaks involving the gastrointestinal tract: a large case series.United European Gastroenterol J. 2016; 4: 770-777
- A large multicenter experience with endoscopic suturing for management of gastrointestinal defects and stent anchorage in 122 patients: A retrospective review.J Clin Gastroenterol. 2016; 50: 388-392
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Published online: September 27, 2022
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© 2022 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc.
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