S2362 Colopancreatic Fistula: The OTSC Connection Closure

Abstract

INTRODUCTION: Enteric fistulas are a rare complication of necrotizing pancreatitis typically connecting with a pancreatic pseudocyst or abscess. Colopancreatic fistulas (CPFs) are very uncommon and have a complicated course as they are unlikely to close spontaneously and can lead to peritonitis and death. Colectomy with fistula repair is commonly performed with unclear data on endoscopic management. We present a case of CPF managed endoscopically with an over-the-scope clip (OTSC) system. CASE DESCRIPTION/METHODS: Our patient is a 57 year old male who initially presented with severe necrotizing pancreatitis and two months later developed a large infected pancreatic pseudocyst measuring 17 cm × 15 cm x 27cm occupying the peripancreatic, abdominal, and pelvic space. EUS-guided cystogastrostomy was unable to be performed and IR-guided drainage was performed. Over the next several months, the patient had recurrent IR guided drainage with improvement over time; however, on one drainage change, a CPF was noted with enterococcus faecium noted on drainage culture. ERCP showed no evidence of pancreatic duct disruption. Resolution of the pseudocyst was observed on CT; however, there was persistent CPF noted on repeat imaging (Figure 1). There was subsequent development of a retroperitoneal fluid collection and a percutaneous IR guided drain was placed. Throughout his course, the patient was symptomatic with abdominal pain, nausea, and vomiting. We made the decision to perform colonoscopic ablation with OTSC closure. Methylene blue was injected through the percutaneous drain into the colon to confirm the fistula site (Figure 2). The fistula site was ablated for de-epithelialization with APC and an 11/6T OTSC was placed (Figure 3). Further injection of methylene blue did not enter the colon. Subsequent sinogram 2 weeks later showed fistula resolution and the fluid collection had resolved with symptom improvement. DISCUSSION: CPF is a rare complication of necrotizing pancreatitis that is difficult to manage and typically requires surgical intervention. Endoscopic clipping for CPF has been previously noted in the literature. There is one prior case report of CPF managed with the OTSC system noted. This case highlighted the persistence and morbidity associated with CPFs. This patient was able to avoid surgical intervention. The OTSC system appears to be effective in the management of CPFs and should be further investigated.Figure 1.: Methylene blue injection showing persistent CPF.Figure 2.: APC ablation for de-epithelialization of CPF.Figure 3.: Deployed OTSC at the de-epithelialized site.