Billroth II gastrectomy complicated by gastrojejunocolonic fistulas, treated endoscopically with a cardiac septal defect closure device

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]).

Video 1 Technique for endoscopic implantation of an Amplatzer device for the occlusion of a gastrocolonic fistula.

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.

Fig. 1 Axial computed tomography (CT) enteroclysis demonstrating a fistula between the greater curvature of the stomach and the transverse colon (arrow).

Fig. 2 Endoscopic appearance of two neighboring fistulas discharging fecal material (white arrows) close to the gastroenteroanastomosis (black arrow).

Fig. 3 Endoscopic view of the orifices of the two gastrojejunocolic fistulas occluded by the Amplatzer device. The arrow is indicating the tip of the delivery catheter attached to the endoscope.

Fig. 4 Endoscopic appearance of the bile-stained Amplatzer device 1 week after placement.

Fig. 5 Upper gastrointestinal study with Gastrografin 1 week after the placement of the Amplatzer device.

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