Endoscopic treatment of a large post-surgical fistula using combined fibrin glue spray and vicryl mesh

摘要

A 72-year old woman underwent a video-laparo duodeno-jejunal resection with a gastro-jejunal anastomosis for adeno-carcinoma of the fourth duodenal portion. Because of hyper-pyrexia and fluid material in abdominal drainages, the patient underwent abdominal Computed Tomography that revealed a 4 cm x 5 cm peri-anastomotic fluid collection. An esophagogastro-duodenoscopy (EGD) showed a leak of 1 cm in diameter, promptly treated by endoscopic positioning of a 10 mm traumatic over-the-scope clip (OTSC) following unsuccessful positioning of endoclips (reusable Olympus EZ Clip system). A naso-jejunal tube was additionally placed and i.v. antibiotic therapy was administered. After 7 days, a second endoscopy revealed the persistence of the anas-tomotic leak with the OTSC partially detached. Failure of OTSC was probably due to an underestimation of leak size or a partially fibrotic mucosal edge. Thus, we removed the OTSC and a fully covered self-expandable metallic Niti-Stent (20 mm x 10 cm, Taewoong Inc.) was applied across the fistulous tract in order to cover it. Because of the high quantity of fluid material in drainages a new EGD was performed showing a large anastomotic leak estimated 5 cm in diameter. Thus, a combined endoscopic technique was adopted to obtain the healing of this fistula using an operative double channel endoscope.