Treatment of duodenal fistula with combined endoscopic therapy: modified endoscopic vacuum, endoscopic internal drainage, and the over-the-scope clip

GI fistulas are often severe adverse events associated with high morbidity and mortality. 1,2Recently, several endoscopic techniques have been developed and have proven to be effective in the treatment of GI fistulas.However, in some specific cases, a combination of endoscopic techniques may be necessary to achieve better results. [3][4]][5][6][7] We report a case of duodenal fistula successfully treated with 3 complementary endoscopic techniques (Video 1, available online at www.videogie.org).A 22-year-old man presented as a trauma victim of a motorcycle accident with multiple fractures throughout the body and duodenal perforation.He was unsuccessfully treated surgically with local sutures twice, evolving with dehiscence of the duodenal suture.Thirty days after the trauma and treatment failure, he was transferred to a referral hospital.Computed tomography showed an intra-abdominal loculated collection containing gas foci and air-fluid level located in the right paracolic gutter extending to the ipsilateral pararenal space and hepatorenal space, measuring approximately 15.9 6.8 4.2 cm with volume 240 mL, illustrated in Figure 1.As the result of hemodynamic stability, endoscopic evaluation and conservational treatment were chosen.A gastroscope was used with auxiliary carbon dioxide.A large perforation was confirmed in the second duodenal portion, approximately 2.0 cm distal and contralateral to the major ampulla, measuring approximately 25 mm in diameter.On entering the perforation, we accessed a septated periduodenal cavity with necrotic tissue and suture thread (Fig. 2).Initially, endoscopic debridement of the periduodenal cavity was performed using a cap, polypectomy loop, and foreign body forceps, as illustrated in Figure 3A.Still, during the first examination, after cavity debridement, endoscopic treatment with negative pressure was chosen. 3 modified endoscopic vacuum suction nasocavity drain was developed and placed endoscopically within the periduodenal cavity, applying continuous negative pressure at 125 mm Hg. 8 Endoscopic vacuum changes were initially performed every 7 days but were later extended between 10 and 14 days as the result of technical difficulty in positioning (Fig. 3B). Figure 1.Computed tomography with coronal section.The red arrow highlights the abscess located in the hepatorenal space.