2167 Endoscopic Closure of a Duodeno-Pleural Fistula Secondary to Transarterial Chemoembolization

Abstract

INTRODUCTION: Transarterial chemoembolization (TACE) is an increasingly performed treatment for advanced stage hepatocellular carcinoma (HCC) not amenable to surgical intervention. Though effective, it is not without risk. Notable complications include post-embolization syndrome, decompensation of cirrhosis, acute cholecystitis, and acute pancreatitis, and rarely hepatic artery injury, liver abscess, duodenal perforation, and bile duct injury. Fistula formation appears to be among the rarest of complications. We describe the presentation of a duodeno-pleural fistula as a complication of TACE and its endoscopic closure with an over-the-scope clip (OTSC). CASE DESCRIPTION/METHODS: A 49-year-old woman with a history of chronic hepatitis B cirrhosis and HCC presented to the emergency room with right-sided chest pain. She was diagnosed with HCC 16 years ago in China and underwent partial hepatectomy and chemotherapy. Two years prior to current presentation, MRI demonstrated a 2.0 × 2.7 × 3.3 cm liver lesion consistent with recurrent HCC. TACE was performed. She subsequently reported abdominal pain. Endoscopy discovered a duodenal ulcer, and imaging noted a developing phlegmon and free air. Management with bowel rest and parenteral nutrition led to clinical improvement without the need for surgery. On this presentation, she described new onset pleuritic chest pain and dyspnea. Imaging revealed a large loculated right pleural effusion with gas foci and visible extraluminal enteric contrast surrounding the duodenal bulb, suggestive of an empyema secondary to a duodeno-pleural fistula (Figure 1). Pleural fluid analysis showed a pH < 6.8, high amylase and lipase levels, and cultures of multiple enteric organisms. Fistula closure was attempted endoscopically. A 4 mm opening was found in the duodenal bulb (Figure 2). The mucosa was denuded with argon beam plasma coagulation and an 11/6t OTSC successfully closed the defect (Figure 3a,b). Extravasated contrast was not seen on imaging two days later. DISCUSSION: Endoscopic interventions for enteric fistula closure include suturing, stents, and clips. The OTSC is increasingly recognized as a minimally invasive technique for fistula closure, with strong immediate technical success rates and variable long-term clinical success depending on location. To our knowledge, we demonstrated the first endoscopic closure of a duodeno-pleural fistula. This case supports the role of endoscopic closure with OTSC for enteric fistulae in the non-surgical candidate.