E134 UCTN – Unusual cases and technical notes

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

Gastrojejunocolonic fistula is a severe Fig. 1 Axial computed complication of gastrectomy with mainly tomography (CT) en- Billroth II reconstruction carried out for teroclysis demonstrat- peptic ulcer or malignant disease. It may ing a fistula between develop 1 –20 years after the procedure. the greater curvature Since the small bowel is bypassed, malnu- of the stomach and trition due to malabsorption occurs [1,2]. the transverse colon (arrow). 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 perfo- rated duodenal ulcer 21 years ago. Barium meal and computed tomography entero- clysis studies revealed fistulous tracts be- tween the transverse colon, the upper je- junum, and the gastric remnant (●" Fig. 1). Upper gastrointestinal endoscopy con- firmed the above findings and showed fecal material into the gastric remnant lumen (●" Fig. 2). The patient refused sur- gery 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 Fig. 2 Endoscopic appearance of two neigh- upload, guide, and deploy the Amplatzer boring fistulas discharging fecal material (white Fig. 4 Endoscopic appearance of the bile- device through the wide fistula tract arrows) close to the gastroenteroanastomosis stained Amplatzer device 1 week after place- (black arrow). (●" Fig. 3,●" Video 1). ment. 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 patientʼs condition im- This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. proved 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

Video 1 Fig. 3 Endoscopic view of the orifices of the two gastrojejunocolic fistulas occluded by the Technique for endoscopic implantation of an Amplatzer device. The arrow is indicating the Fig. 5 Upper gastrointestinal study with Gas- Amplatzer device for the occlusion of a gastro- tip of the delivery catheter attached to the en- trografin 1 week after the placement of the colonic fistula. doscope. Amplatzer device.

Kouklakis G et al. Gastrojejunocolonic fistulas treated with a cardiac septal defect closure device… Endoscopy 2010; 42: E134 –E135 UCTN – Unusual cases and technical notes E135

fistula and re-establishment of gastrojeju- 2 1st Department of Surgery, Democritus tula: novel application of a cardiac septal de- nal and colonic continuity [2,4]. However, University of Thrace, University General fect closure device (with video). Gastroin- test Endosc 2009; 70: 542– 545 nonoperative medical management strat- Hospital of Alexandroupolis, Alexandrou- 4 Filipovic B, Randjelovic T, Nikolić G. Gastroje- egies have also been proposed [5]. This is polis, Greece junocolic fistula as a complication of Billroth the first case of implantation of an Am- 3 2nd Department of Surgery, Democritus II gastrectomy: a case report. Acta Chir Belg platzer atrial septal defect closure device University of Thrace, University General 2008; 108: 592– 594 5 Rots WI, Mokoena T. Successful endoscopic to occlude two gastrojejunocolonic fistu- Hospital of Alexandroupolis, Alexandrou- closure of a benign gastrocolonic fistula las with a novel delivery method in the polis, Greece using human fibrin sealant through gastro- complicated setting of a Billroth II recon- 4 Department of Pathology, Democritus scopic approach: a case report and review struction. This approach could be an alter- University of Thrace, University General of the literature. Eur J Gastroenterol Hepatol – native to surgical management in certain Hospital of Alexandroupolis, Alexandrou- 2003; 15: 1351 1356 circumstances, especially in patients with polis, Greece a high operative risk. 5 Department of Radiology, Democritus Bibliography University of Thrace, University General DOI 10.1055/s-0029-1244058 Endoscopy 2010; 42: E134 –E135 Competing interests: None Hospital of Alexandroupolis, Alexandrou- © Georg Thieme Verlag KG Stuttgart · New York · polis, Greece ISSN 0013-726X Endoscopy_UCTN_Code_TTT_1AO_2AI References Corresponding author G. Kouklakis1, P. Zezos1, N. Liratzopou- 1 Cody JH, DiVincenti FC, Cowick DR et al. Gas- P. Zezos, MD los2, M. Pitiakoudis3, E. Efremidou2, trocolic and gastrojejunocolic fistulae: re- Gastrointestinal Endoscopy Unit, port of twelve cases and review of the litera- 4 5 Democritus University of Thrace, A. Giatromanolaki , N. Courcoutsakis , ture. Ann Surg 1975; 181: 376– 380 3 University General Hospital of Alexandroupolis C. Simopoulos 2 Ohta M, Konno H, Tanaka T et al. Gastrojeju- 40 Venizelou Str 1 Gastrointestinal Endoscopy Unit, Demo- nocolic fistula after gastrectomy with Bill- 68100 Alexandroupolis critus University of Thrace, University roth II reconstruction: report of a case. Surg – Greece General Hospital of Alexandroupolis, Today 2002; 32: 367 370 3 Melmed GY, Kar S, Geft I et al. A new method Fax: +30-25510-84168 Alexandroupolis, Greece for endoscopic closure of gastrocolonic fis- [email protected] This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.

Kouklakis G et al. Gastrojejunocolonic fistulas treated with a cardiac septal defect closure device… Endoscopy 2010; 42: E134– E135