VideoGIE
gallbladder. The patient was transferred to our institution for palliation of the malignant fistula to optimize nutritional status for 6 to 8 weeks before definitive resection. Repeat endoscopy demonstrated a large duodenal fistula (Fig. 1A; Video 1, available online at www.giejournal. org). An 18 mm 10 cm through-the-scope, fully covered, self-expandable, metal stent (FCSEMS) was deployed under endoscopic and fluoroscopic guidance, extending past the fistulous tract. In order to prevent distal migration of the stent, we used a PEG-based anchoring system. A suture was advanced through the PEG and was looped through a puncture hole in the covering of the stent (Fig. 1B). A follow-up CT scan demonstrated closure of the fistulous tract, and the patient was maintained on oral nutrition until her surgery. Although the method has not been approved for delayed removal, there has been extensive clinical experience with the use of FCSEMSs for the treatment of esophageal fistulae and anastomotic leaks, with excellent clinical efficacy despite a high migration rate. Distal
migration of an FCSEMS in the duodenum carries a significant risk of small-bowel adverse events. This case represents the novel use of an FCSEMS for the palliation of a duodenal fistula, with a PEG-based anchoring system to prevent distal migration. DISCLOSURE J. Buscaglia and J. Bucobo are consultants for Boston Scientific and Cook Medical. All other authors disclosed no financial relationships relevant to this article. Satish Nagula, MD, Jonathan M. Buscaglia, MD, Juan Carlos Bucobo, MD, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Stony Brook University School of Medicine, Stony Brook, New York, USA
http://dx.doi.org/10.1016/j.gie.2014.05.322
Acute duodenal diverticulitis treated with endoscopic therapy
Figure 1. Endoscopic debridement of an infected periampullary diverticulum. A, Endoscopic view of diverticulum disimpaction and drainage. B, Illustration of diverticular cavity disimpaction using a balloon catheter.
2014 VIDEO FORUM WINNER
This video can be viewed directly from the GIE website or by using the QR code and your mobile device. Download a free QR code scanner by searching “QR Scanner” in your mobile device’s app store.
diverticula. A 55-year-old woman was seen with severe, right upper quadrant abdominal pain associated with nausea, fever, tachycardia, and leukocytosis. Fluid resuscitation and broad-spectrum antibiotics were initiated; abdominal CT scan showed a 2.6-cm cystic structure containing gas near the head of the pancreas, suggestive of duodenal diverticulitis. On endoscopy, a large periampullary diverticulum with food and debris impacted in the diverticular cavity was noted. Disimpaction with an extraction balloon was performed (Fig. 1; Video 1, available online at www.giejournal.org), followed by irrigation with normal saline solution, resulting in
522 GASTROINTESTINAL ENDOSCOPY Volume 80, No. 3 : 2014
www.giejournal.org
Duodenal diverticulitis, resulting from impaction of bowel contents, is a rare adverse event of periampullary
VideoGIE
drainage of a large amount of pus and debris. Contrast injection was performed to exclude a fistula or a contained perforation. Two 7F 4-cm double-pigtail stents were placed. Rapid defervescence and marked improvement of abdominal pain was noted. Follow-up imaging 2 weeks later revealed a normal-appearing diverticulum without residual food or debris. Stents were removed 3 weeks later. A high degree of suspicion is required for a diagnosis of duodenal diverticulitis on cross-sectional imaging. In the absence of perforation, endoscopic therapies including debridement, irrigation, and stent placement can be effective when conservative management fails and may be a viable alternative to surgery.
DISCLOSURE All authors disclosed no financial relationships relevant to this article. Wajeeh Salah, MD, M. Edwyn Harrison, MD, Douglas O. Faigel, MD, Rahul Pannala, MD, Mayo Clinic Arizona, Phoenix, Arizona, USA
http://dx.doi.org/10.1016/j.gie.2014.05.303
Successful closure of a Billroth II duodenal stump leak with fistulization to the colon by use of stacked over-the-scope clips
Figure 1. A, Sinogram showing duodenal stump leak and fistula to the colon. B, Placement of an over-the-scope clip to close the entire duodenal lumen. C, Successful closure of the fistula after placement of 2 over-the-scope clips (arrows).
www.giejournal.org
Volume 80, No. 3 : 2014 GASTROINTESTINAL ENDOSCOPY 523
gallbladder. The patient was transferred to our institution for palliation of the malignant fistula to optimize nutritional status for 6 to 8 weeks before definitive resection. Repeat endoscopy demonstrated a large duodenal fistula (Fig. 1A; Video 1, available online at www.giejournal. org). An 18 mm 10 cm through-the-scope, fully covered, self-expandable, metal stent (FCSEMS) was deployed under endoscopic and fluoroscopic guidance, extending past the fistulous tract. In order to prevent distal migration of the stent, we used a PEG-based anchoring system. A suture was advanced through the PEG and was looped through a puncture hole in the covering of the stent (Fig. 1B). A follow-up CT scan demonstrated closure of the fistulous tract, and the patient was maintained on oral nutrition until her surgery. Although the method has not been approved for delayed removal, there has been extensive clinical experience with the use of FCSEMSs for the treatment of esophageal fistulae and anastomotic leaks, with excellent clinical efficacy despite a high migration rate. Distal
migration of an FCSEMS in the duodenum carries a significant risk of small-bowel adverse events. This case represents the novel use of an FCSEMS for the palliation of a duodenal fistula, with a PEG-based anchoring system to prevent distal migration. DISCLOSURE J. Buscaglia and J. Bucobo are consultants for Boston Scientific and Cook Medical. All other authors disclosed no financial relationships relevant to this article. Satish Nagula, MD, Jonathan M. Buscaglia, MD, Juan Carlos Bucobo, MD, Division of Gastroenterology and Hepatology, Department of Internal Medicine, Stony Brook University School of Medicine, Stony Brook, New York, USA
http://dx.doi.org/10.1016/j.gie.2014.05.322
Acute duodenal diverticulitis treated with endoscopic therapy
Figure 1. Endoscopic debridement of an infected periampullary diverticulum. A, Endoscopic view of diverticulum disimpaction and drainage. B, Illustration of diverticular cavity disimpaction using a balloon catheter.
2014 VIDEO FORUM WINNER
This video can be viewed directly from the GIE website or by using the QR code and your mobile device. Download a free QR code scanner by searching “QR Scanner” in your mobile device’s app store.
diverticula. A 55-year-old woman was seen with severe, right upper quadrant abdominal pain associated with nausea, fever, tachycardia, and leukocytosis. Fluid resuscitation and broad-spectrum antibiotics were initiated; abdominal CT scan showed a 2.6-cm cystic structure containing gas near the head of the pancreas, suggestive of duodenal diverticulitis. On endoscopy, a large periampullary diverticulum with food and debris impacted in the diverticular cavity was noted. Disimpaction with an extraction balloon was performed (Fig. 1; Video 1, available online at www.giejournal.org), followed by irrigation with normal saline solution, resulting in
522 GASTROINTESTINAL ENDOSCOPY Volume 80, No. 3 : 2014
www.giejournal.org
Duodenal diverticulitis, resulting from impaction of bowel contents, is a rare adverse event of periampullary
VideoGIE
drainage of a large amount of pus and debris. Contrast injection was performed to exclude a fistula or a contained perforation. Two 7F 4-cm double-pigtail stents were placed. Rapid defervescence and marked improvement of abdominal pain was noted. Follow-up imaging 2 weeks later revealed a normal-appearing diverticulum without residual food or debris. Stents were removed 3 weeks later. A high degree of suspicion is required for a diagnosis of duodenal diverticulitis on cross-sectional imaging. In the absence of perforation, endoscopic therapies including debridement, irrigation, and stent placement can be effective when conservative management fails and may be a viable alternative to surgery.
DISCLOSURE All authors disclosed no financial relationships relevant to this article. Wajeeh Salah, MD, M. Edwyn Harrison, MD, Douglas O. Faigel, MD, Rahul Pannala, MD, Mayo Clinic Arizona, Phoenix, Arizona, USA
http://dx.doi.org/10.1016/j.gie.2014.05.303
Successful closure of a Billroth II duodenal stump leak with fistulization to the colon by use of stacked over-the-scope clips
Figure 1. A, Sinogram showing duodenal stump leak and fistula to the colon. B, Placement of an over-the-scope clip to close the entire duodenal lumen. C, Successful closure of the fistula after placement of 2 over-the-scope clips (arrows).
www.giejournal.org
Volume 80, No. 3 : 2014 GASTROINTESTINAL ENDOSCOPY 523
