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DOI: 10.1055/s-0029-1244058
© Georg Thieme Verlag KG Stuttgart · New York
Billroth II gastrectomy complicated by gastrojejunocolonic fistulas, treated endoscopically with a cardiac septal defect closure device
P. ZezosMD
Gastrointestinal Endoscopy Unit, Democritus University of Thrace, University General Hospital of Alexandroupolis
40 Venizelou Str
68 100 Alexandroupolis
Greece
Fax: +30-25510-84168
Email: zezosp@hol.gr
Publication History
Publication Date:
19 April 2010 (online)
Gastrojejunocolonic fistula is a severe complication of gastrectomy with mainly Billroth II reconstruction carried out for peptic ulcer or malignant disease. It may develop 1 – 20 years after the procedure. Since the small bowel is bypassed, malnutrition due to malabsorption occurs [1] [2].
A 58-year-old Greek man was admitted for fecal-smelling eructation, diarrhea, and weight loss during the past year. He had undergone a distal gastric resection with Billroth II reconstruction for a perforated duodenal ulcer 21 years ago. Barium meal and computed tomography enteroclysis studies revealed fistulous tracts between the transverse colon, the upper jejunum, and the gastric remnant ([Fig. 1]). Upper gastrointestinal endoscopy confirmed the above findings and showed fecal material into the gastric remnant lumen ([Fig. 2]). The patient refused surgery and after malignancy was excluded, we attempted to occlude both fistulas with the Amplatzer atrial septal defect closure device (9-ASD-040; AGA Medical Corp., Plymouth, Minnesota, USA), an idea based on the report of Melmed et al. [3]. We modified the technique of device delivery by using the endoscope itself to upload, guide, and deploy the Amplatzer device through the wide fistula tract ([Fig. 3], [Video 1]).
Quality:
The procedure was uneventful and 1 week later, an endoscopy showed the device at the gastroenterostomy site without fecal material into the gastric lumen ([Fig. 4]); a small but functionally insignificant leakage of Gastrografin was also noted ([Fig. 5]). The patient's condition improved with cessation of fecal-smelling eructation and diarrhea and an increase in appetite and weight.
It is recommended that malnutrition should be corrected and radical surgery carried out with resection of the entire fistula and re-establishment of gastrojejunal and colonic continuity [2] [4]. However, nonoperative medical management strategies have also been proposed [5]. This is the first case of implantation of an Amplatzer atrial septal defect closure device to occlude two gastrojejunocolonic fistulas with a novel delivery method in the complicated setting of a Billroth II reconstruction. This approach could be an alternative to surgical management in certain circumstances, especially in patients with a high operative risk.
Competing interests: None
Endoscopy_UCTN_Code_TTT_1AO_2AI
#References
- 1 Cody J H, DiVincenti F C, Cowick D R. et al . Gastrocolic and gastrojejunocolic fistulae: report of twelve cases and review of the literature. Ann Surg. 1975; 181 376-380
- 2 Ohta M, Konno H, Tanaka T. et al . Gastrojejunocolic fistula after gastrectomy with Billroth II reconstruction: report of a case. Surg Today. 2002; 32 367-370
- 3 Melmed G Y, Kar S, Geft I. et al . A new method for endoscopic closure of gastrocolonic fistula: novel application of a cardiac septal defect closure device (with video). Gastrointest Endosc. 2009; 70 542-545
- 4 Filipovic B, Randjelovic T, Nikolić G. Gastrojejunocolic fistula as a complication of Billroth II gastrectomy: a case report. Acta Chir Belg. 2008; 108 592-594
- 5 Rots W I, Mokoena T. Successful endoscopic closure of a benign gastrocolonic fistula using human fibrin sealant through gastroscopic approach: a case report and review of the literature. Eur J Gastroenterol Hepatol. 2003; 15 1351-1356
P. ZezosMD
Gastrointestinal Endoscopy Unit, Democritus University of Thrace, University General Hospital of Alexandroupolis
40 Venizelou Str
68 100 Alexandroupolis
Greece
Fax: +30-25510-84168
Email: zezosp@hol.gr
References
- 1 Cody J H, DiVincenti F C, Cowick D R. et al . Gastrocolic and gastrojejunocolic fistulae: report of twelve cases and review of the literature. Ann Surg. 1975; 181 376-380
- 2 Ohta M, Konno H, Tanaka T. et al . Gastrojejunocolic fistula after gastrectomy with Billroth II reconstruction: report of a case. Surg Today. 2002; 32 367-370
- 3 Melmed G Y, Kar S, Geft I. et al . A new method for endoscopic closure of gastrocolonic fistula: novel application of a cardiac septal defect closure device (with video). Gastrointest Endosc. 2009; 70 542-545
- 4 Filipovic B, Randjelovic T, Nikolić G. Gastrojejunocolic fistula as a complication of Billroth II gastrectomy: a case report. Acta Chir Belg. 2008; 108 592-594
- 5 Rots W I, Mokoena T. Successful endoscopic closure of a benign gastrocolonic fistula using human fibrin sealant through gastroscopic approach: a case report and review of the literature. Eur J Gastroenterol Hepatol. 2003; 15 1351-1356
P. ZezosMD
Gastrointestinal Endoscopy Unit, Democritus University of Thrace, University General Hospital of Alexandroupolis
40 Venizelou Str
68 100 Alexandroupolis
Greece
Fax: +30-25510-84168
Email: zezosp@hol.gr