2139 Endoscopic Closure of Post-Operative Duodenal-Enteric Fistula Following Repair of Abdominal Gunshot Wounds

Abstract

INTRODUCTION: Gastrointestinal defects including enteric duodenal fistulas cause complications such as infection and multiorgan failure, which may lead to death. The gold standard is surgical closure; however, this requires repeat surgeries and may lead to post-operative complications. The over the scope clip (OTSC) is known to be an effective and safe modality for GI defects such as perforation and GI tract leaks, but studies have shown limited success for closure of gastrointestinal fistulous tracts and is dependent on the anatomical location and size of the defect. We report a case where an OTSC was used successfully for immediate closure of a duodenal-enteric fistula caused by a gunshot wound, which saved the patient from undergoing additional surgery. CASE DESCRIPTION/METHODS: A 41-year-old man presented with multiple gunshot wounds to the abdomen. An emergent exploratory laparotomy was performed, with partial small bowel resection for gunshot wounds to the jejunum and ileum. His post-operative course was complicated by an intra-abdominal abscess. A sinogram revealed a duodenal-enteric fistula with a fluid collection, requiring Jackson Pratt drain placement and antibiotic therapy (A). Given the lack of improvement, the patient was taken for esophagogastroduodenoscopy (EGD). A 10 mm fistulous tract was identified at the junction of the 2nd and 3rd portion of the duodenum (B). A 12/6t OTSC was deployed over a pediatric colonoscope. The scope was passed to the level of the fistula, with fluoroscopy for localization. Using suction, the fistula was pulled into the cap of the OTSC device and the clip was successfully deployed, closing the fistula (C). Clip placement was confirmed via fluoroscopy. The next day, upper gastrointestinal stomach X-Ray was completed and did not show extravasation to suggest a leak at the duodenum. His diet was advanced and after a prolonged hospital course, he was discharged. DISCUSSION: This case highlights the use of OTSC for a fistula caused by trauma rather than common causes such as bariatric surgery, percutaneous gastrostomy tube placement, or an underlying malignancy. Although technically challenging, when used as primary therapy, OTSC closure of an enteric fistulous tract has the potential to reduce the need for an emergent surgery. Therefore, OTSC closure should be considered an effective therapeutic modality in patients with trauma-related abdominal enteric fistulas.