Successful Endoscopic Management of a Malignant Gastro-Retroperitoneal Fistula

Abstract

Introduction Malignant involvement of the gastrointestinal (GI) tract causing fistula is rare and can lead to infections, malnutrition, poor quality of life and sometimes become life-threatening. Surgical treatment can be challenging especially in patients with severe malnutrition and poor functional status. Endoscopic management can sometimes improve the patient nutrition allowing them to have definitive treatment whether surgical or systemic therapy. We present a case of gastric fistula due to involvement with lymphoma who was successfully managed initially endoscopically and then with systemic therapy. Case A 55-year-old man presented with few weeks history of left sided abdominal pain and 22 pounds weight loss. He appeared cachectic. Abdominal CT scan showed a retroperitoneal mass and abscess with oral contrast extravasation into the abscess cavity consistent with a gastric fistula. Biopsy of the mass showed lymphoma. The patient was a poor surgical candidate given his comorbidities, malnutrition and poor functional status. He was managed in a multidisciplinary fashion with percutaneous drainage of his abscess, endoscopic closure of his fistula followed by systemic therapy. Endoscopic closure consisted of ablation of the fistula track with Argon Plasma coagulation, then multilayer suturing to close the gastric wall defect. A gastrojejunal tube was placed to divert the flow from the fistula tract and improve his nutrition. Three weeks later, endoscopy showed the fistula has closed. At that time, his functional and nutritional status improved allowing him to start chemotherapy. Follow up CT scan in 3 months showed resolution of the abscess and lack of contrast extravasation. The GJ tube was removed and the patient started to eat normally. He was disease-free on 5 months follow up and his functional status returned to baseline. Discussion This case illustrates the successful multidisciplinary management of a complex fistula in a patient who is a poor surgical candidate. The approach included ablation of the fistula tract, multilayer suturing of the fistula, diversion of flow away from the fistula, draining the underlying abscess, improving nutritional status and treating the underlying malignancy. Endoscopy played a major role in his management. Endoscopic techniques and tools continue to evolve making the therapeutic endoscopist more versatile, with an ever-expanding role in the management of complex GI conditions previously tackled by surgery. Watch the video: https://goo.gl/nxiqwV1678_A Figure 1. Endoscopy showing small defect in the posterior wall of the stomach. Figure (B): Endoscopy showing gastro-retroperitoneal fistula, and retroperitoneal abscess.1678_B Figure 2. CT scan showing Retroperitoneal mass and air, suggestive of a retroperitoneal abscess. Figure (D): CT scan showing resolution of the abscess and lack of contrast extravasation after fistula closure1678_C Figure 3. Endoscopy showing final outcome of suturing.