Over-the-scope clip closure of an iatrogenic gastro-colic fistula following maldeployment of a lumen-apposing metal stent

A 44-year-old man with a 3-month history of necrotizing pancreatitis was referred for endoscopic ultrasound (EUS)-guided drainage of infected 12 × 5 cm symptomatic walled-off necrosis (WON) [1] ([Fig. 1 a]). At EUS, a large partially cystic/solid lesion, interpreted as the WON, was identified. A 20-mm lumen-apposing metal stent (LAMS; Hot AXIOS, Boston Scientific, Marlborough, Massachusetts, USA) and plastic pigtail stent were deployed through the posterior gastric wall. The patient was well following the procedure. However, computed tomography (CT) revealed that the LAMS had been incorrectly deployed into the colon ([Fig. 2]), and the WON had spontaneously improved (3 × 2 cm) ([Fig. 1 b]).

Fig. 1 Computed tomography. a Symptomatic walled-off necrosis (WON). b Spontaneously improved WON.

Fig. 2 Maldeployed lumen-apposing metal stent (arrows) and plastic pigtail stent. a, b X-ray. c Computed tomography scan.

We planned to remove the LAMS endoscopically and close the gastro-colic fistula (GCF) by over-the-scope-clips (OTSCs) [2] [3] ([Video 1]). Colonic cleansing necessitated a nasojejunal tube to bypass the GCF.

Video 1 Over-the-scope clip closure of an iatrogenic gastro-colic fistula following maldeployment of a lumen-apposing metal stent.

Simultaneous upper and lower gastrointestinal endoscopy were performed under general anesthesia. The colonoscope, loaded with a 14-mm OTSC (Ovesco, Tübingen, Germany), was inserted to the LAMS at the splenic flexure. The LAMS was removed with the gastroscope. The colonic defect was closed with the OTSC using twin-grasping forceps tissue apposition ([Fig. 3]), followed by similar closure of the gastric defect with two 12-mm OTSCs. Successful closure was confirmed endoscopically and radiologically with indigo carmine dye and contrast, respectively ([Fig. 4]). Although the patient developed some delayed localized pain and peritonism 48 hours after oral intake, repeat contrast CT showed no leakage ([Fig. 5 a]). Symptoms settled conservatively with antibiotics and temporary intravenous nutrition. The patient was discharged 10 days after the procedure, with a pre-discharge contrast meal re-confirming no leakage ([Fig. 5 b]).

Fig. 3 Twin-grasping forceps tissue apposition used to close the colonic defect with the over-the-scope clip.

Fig. 4 Successful closure was confirmed radiologically with contrast.

Fig. 5 Post-procedure tests confirming no leakage. a Computed tomography. b Barium meal showing no leakage.

To the best of our knowledge, this is the first case of successful OTSC closure of an acute GCF caused by a maldeployed LAMS, confirming the role of OTSCs in minimally invasive endoscopic management of such complications.

Endoscopy_UCTN_Code_CPL_1AL_2AG

Publication History

Article published online:
21 February 2020

• References

• 1 Itoi T, Binmoeller KF, Shah J. et al. Clinical evaluation of a novel lumen-apposing metal stent for endosonography-guided pancreatic pseudocyst and gallbladder drainage (with videos). Gastrointest Endosc 2012; 75: 870-876
• 2 Murino A, Despott EJ, Vaizey C. et al. First report of endoscopic closure of a gastrocolic fistula using an over-the-scope clip system (with video). Gastrointest Endosc 2012; 75: 893-894
• 3 Mönkemüller K, Peter S, Alkurdi B. et al. Endoscopic closure of a gastrocolic fistula using the over-the-scope-clip-system. World J Gastrointest Endosc 2013; 5: 402-406