Failure Of Endoscopic Treatment Research Articles

Double tracheoesophageal fistula after prolonged intubation during COVID-19: surgical treatment by colonic transposition in the retrosternal space

This is a patient with 2 tracheoesophageal fistulas following prolonged intubation due to COVID-19 with severe evolution and indication for surgical treatment due to failure of endoscopic treatment. Patient in a long hospital stay, unable to eat an oral diet, malnourished, chronic cough, developing persistent pneumonia due to recurrent salivary bronchoaspiration. The case was treated by complex surgical intervention consisting of proximal and distal partial esophagectomy with reconstruction of food transit by colonic bypass in the anterior mediastinum, resection and tracheal reanastomosis. The final result was good, with the patient being discharged from the hospital on a restored oral diet and free spontaneous breathing. The resolution of an extremely serious case through a complex and exceptional surgical approach, which imposed enormous challenges in pre-operative preparation and detailed therapeutic planning, with single-stage surgical action by two surgical teams (Digestive System Surgery and Thoracic Surgery).

Double tracheoesophageal fistula after prolonged intubation during COVID-19: surgical treatment by colonic transposition in the retrosternal space

This is a patient with 2 tracheoesophageal fistulas following prolonged intubation due to COVID-19 with severe evolution and indication for surgical treatment due to failure of endoscopic treatment. Patient in a long hospital stay, unable to eat an oral diet, malnourished, chronic cough, developing persistent pneumonia due to recurrent salivary bronchoaspiration. The case was treated by complex surgical intervention consisting of proximal and distal partial esophagectomy with reconstruction of food transit by colonic bypass in the anterior mediastinum, resection and tracheal reanastomosis. The final result was good, with the patient being discharged from the hospital on a restored oral diet and free spontaneous breathing. The resolution of an extremely serious case through a complex and exceptional surgical approach, which imposed enormous challenges in pre-operative preparation and detailed therapeutic planning, with single-stage surgical action by two surgical teams (Digestive System Surgery and Thoracic Surgery).

Predictive role of ureteral wall thickness and patient characteristics in endoscopic treatment outcomes for ureteral stricture disease following stone surgery

PurposeTo evaluate the role of certain radiological parameters and patient characteristics in predicting the success of endoscopic treatment in ureteral stricture disease.MethodsFifty one adult patients with ureteral stricture disease (< 1 cm) after developing due to upper ureteral stones with ureteroscopic laser disintegration were included and in addition to stone and patient parameters, radiological parameters including ureteral wall thickness (UWT) at the impacted stone site were also measured on computed tomography (CT) images. Patients were divided into two groups: Group 1: Patients with endoscopic treatment success and Group 2: Patients with endoscopic treatment failure. The possible relationship between the UWT values and other radiological parameter was comparatively evaluated.ResultsMean UWT value assessed at the treated stone site was significantly higher in cases unresponsive to endoscopic treatment with values of 2.77 ± 1.03 mm and 4.25 ± 1.32 mm in Group 1 and 2 respectively. A cut off value 3.55 mm for UWT was found to be highly predictive for endoscopic treatment failure.ConclusionsOur current results indicated that assessment of UWT value at the obstructing stone could be helpful enough to predict the likelihood of failure following endoscopic management of strictures with high sensitivity and specificity. Evaluation of this particular parameter could let the endourologists to look for more rational treatment alternatives with necessary measures taken on time.

Recurrent gastric antral vascular ectasia: a single center experience.

Gastric antral vascular ectasia (GAVE) is a rare cause of chronic or acute gastrointestinal bleeding. This condition accounts for ∼4% of upper gastrointestinal bleeding cases. This disease is often associated with systemic diseases, such as liver cirrhosis, chronic kidney failure, autoimmune conditions, diabetes mellitus, hypothyroidism, and cardiovascular diseases. However, its etiopathogenesis remains controversial. We retrospectively reviewed the cases of GAVE treated at our digestive surgery unit. A total of nine patients were identified with a male/female ratio of 1.25:1 and an average age of 75.51 years (SD ± 9.85). All patients underwent endoscopic argon plasma coagulation (APC) treatment. At the time of the review, data on eight patients were available after 36 months of follow-up. APC appears to be safe and effective for hemostasis of bleeding vascular ectasia. Only one (11.1%) patient required surgical intervention due to hemodynamic instability after multiple unsuccessful endoscopic treatments. No intraoperative and postoperative complication or bleeding relapse was experienced. Based on our findings, we concluded that endoscopic APC is technically simple, but requires multiple re-interventions due to the incidence of relapses. Furthermore, larger randomized studies should be conducted to assess the role of elective surgery as the first intervention in stable patients with severe pathology and the timing of surgery after failed endoscopic treatment.

Robotic Bile Duct Exploration With Primary Closure of Choledochotomy: An Alternative Minimally Invasive Technique After Failure of Endoscopic Treatment.

Robotic Bile Duct Exploration With Primary Closure of Choledochotomy: An Alternative Minimally Invasive Technique After Failure of Endoscopic Treatment.

What are the factors affecting the mound displacement detected in endoscopic treatment failure of vesicoureteral reflux

What are the factors affecting the mound displacement detected in endoscopic treatment failure of vesicoureteral reflux

403. END-STAGE ACHALASIA: FEASIBILITY OF CARDIOMYOTOMY WITH ANTERIOR 90-DEGREE FUNDOPLICATION AS TREATMENT

Abstract Achalasia is a primary motor disorder of the oesophagus. End-stage achalasia is characterised by a grossly dilated sigmoid-shaped oesophagus with food stasis leading to chronic inflammation. Despite treatment, approximately 5% of patients progress to this late stage, needing oesophagectomy. Current guidelines recommend oesophagectomy as the last resort after failure of first-line endoscopic treatment or cardiomyotomy. We review a case of a 70 years old female with end-stage achalasia who successfully underwent cardiomyotomy but required a looser wrap for oesophageal emptying. Patient first presented in her 50s with dysphagia and Oesophago-Gastro-Duodenoscopy (OGD) showed a dilated oesophagus with food stasis and no contractions. Barium swallow confirmed the diagnosis of achalasia. She underwent pneumatic dilatations with minimal symptom improvement and eventually defaulted follow-up. Several years later she presented with haematemesis due to severe oesophagitis and Eckardt score of 7. Both OGD and CT scans showed a grossly dilated megaoesophagus. High-resolution manometry confirmed Type I achalasia with IRP (integrated relaxation pressure) 25.8 and complete absence of peristalsis. She was initiated on nasogastric feeding and was also diagnosed with pulmonary embolism (PE). In view of PE and patient’s comorbidities, she was not fit for oesophagectomy. Peroral endoscopic myotomy (POEM) was also deemed challenging in the presence of severe, chronic oesophagitis and patient’s need for anticoagulation with potential difficulty in endoscopic haemostasis. She underwent laparoscopic cardiomyotomy with anterior 180-degree fundoplication. However, post-operation contrast swallow showed hold up of contrast despite intraoperative OGD showing smooth passage of scope through LES. Decision was made for revision of fundoplication to anterior 90-degree to further promote oesophageal emptying. Post-operation contrast swallow showed satisfactory drainage into stomach and patient tolerated post-fundoplication diet regime. This case illustrates the role of cardiomyotomy as first-line in patients with end-stage achalasia who are not fit for oesophagectomy. However, an anterior 180-degree fundoplication may not allow adequate drainage from a megaoesophagus and a less tight wrap should be considered in such cases. Post-operation, reported Eckardt score of our patient was 1 with no reflux symptoms, indicating marked alleviation of symptoms. Thus, cardiomyotomy with a lesser 90-degree fundoplication is feasible as first-line treatment in end-stage achalasia.

Long-term follow-up of a cohort with post sleeve gastrectomy leaks: results of endoscopic treatment and salvage surgery.

Laparoscopic sleeve gastrectomy (LSG) is the most performed bariatric procedure worldwide. The most challenging postoperative complication is gastric leak. The objectives of this study are to examine the efficacy and morbidity of different therapeutic strategies addressing leakage, and the long-term outcomes of a cohort of LSG leaks. A retrospective review of patients treated for LSG leaks between September 2014 and January 2023 at our high-volume bariatric surgery center was performed. The charts of 37 patients (29 women and 8 men) were reviewed, with a mean age of 43years and a median follow-up of 24months. The mean preoperative body mass index was 45.1kg/m2. Overall, 30/37 (81%) patients were successfully treated with endoscopic management, and 7/37 (19%) ultimately underwent salvage surgery. If the leak was diagnosed earlier than 6weeks, endoscopic treatment had a 97% success rate. The median number of endoscopic procedures was 2 per patient, and included internal pigtails, stents, septoplasty, endoluminal vacuum therapy and over-the-scope clips. Complications included stent-related ulcers (10), esophageal stenosis requiring endoscopic dilatations (4), stent migrations (2) and kinking requiring repositioning (1), and internal pigtail migration (3). Revisional surgery consisted of proximal gastrectomy and Roux-en-Y esophago-jejunal anastomosis, Roux-en-Y fistulo-jejunostomy or classic Roux-en-Y gastric bypass proximal to the gastric stricture. In 62% of the cases, the axis/caliber of the LSG was abnormal. Beyond 4 attempts, endoscopy was unsuccessful. The success rate of endoscopic management dropped to 25% when treatment was initiated more than 45days after the index surgery. Purely endoscopic management was successful in 81% of cases; with 97% success rate if diagnosis earlier than 6weeks. After four failed endoscopic procedures, a surgical approach should be considered. Delayed diagnosis appears to be a significant risk factor for failure of endoscopic treatment.

WTP3.13 Management of early complications of liver transplantation from a living related donor

Abstract Aim The aim of this study is to highlight the importance of the development of adequate surgical technique, the proper selection of donors, the preparation of recipients and the introduction of new molecules of Immunosuppressants in improving liver transplant (LT) outcomes. The study also shows that early complications, occurring within the first 3 months, are responsible for two-thirds of deaths. Methods All LT candidates were assessed for contraindications to immunosuppressants, social and psychiatric assessment, and operative and infectious risk assessment. Patients who received LT were followed according to a rigorous pre-established protocol that allowed the detection of early postoperative complications and surgical revision in some cases. Results Post-operative surgical complications occurred in 04 patients who required immediaterevision surgery for hemoperitoneum, portal thrombosis that required unblockage of the TP, thrombosis of the hepatic artery requiring new arterial anastomosis and liver resection, and one patient developed an infectious complication (MAT). Three patients experienced complications related to immunosuppressants. One patient required renal dialysis. Two patients developed biliary stenosis; treated endoscopically in one patient, and biliary repair after failure of endoscopic treatment in another. Conclusion Hemorrhage, primary graft non-function, multiple organ failure and infection, acute rejection and surgical complications dominate post-LT follow-up. Immunosuppressive treatments are responsible for a significant morbidity rate. Early detection of complications and their immediate management reducing morbidity and mortality. The living related donor LT program remains an option in our country due to the impossibility of LT as part of an ODB.

Outcomes of Robotic Simple Prostatectomy After Prior Failed Endoscopic Treatment of Benign Prostatic Hyperplasia.

Background: We compared outcomes of robot-assisted simple prostatectomy (RASP) in patients with and without a history of prior prostate surgery for management of symptomatic benign prostatic hyperplasia (BPH). Methods: We retrospectively reviewed our multi-institutional database for all consecutive patients who underwent RASP between May 2013 and January 2021. Postoperatively, urinary function was assessed using the American Urological Association symptom score (AUASS) and quality of life (QOL) score. Results: Overall, 520 patients met inclusion criteria. Among the 87 (16.7%) patients who underwent prior prostate surgery, 49 (56.3%), 26 (29.9%), 8 (9.2%), 3 (3.4%), and 1 (1.1%) patients underwent transurethral resection of the prostate, photoselective vaporization of the prostate, transurethral microwave therapy, prostatic urethral lift, or water vapor thermal therapy, respectively. There was no difference in mean prostate volume (p = 0.40), estimated blood loss (p = 0.32), robotic console time (p = 0.86), or major 30-day postoperative (Clavien >2) complications (p = 0.80) between both groups. With regard to urinary function, the mean improvement in preoperative and postoperative AUASS (p = 0.31), QOL scores (p = 0.11), and continence rates was similar between both groups. Conclusion: For management of patients with BPH and lower urinary tract symptoms, RASP is associated with an improvement in urinary function outcomes and a low risk of postoperative complications. Perioperative outcomes of RASP are similar in patients who underwent prior prostate surgery vs those that did not undergo prior prostate surgery.

Intravascular Ultrasound for Transjugular Intrahepatic Portosystemic Shunt Creation: "TIPS" and Tricks.

Cirrhosis affects 4.5 million people in the United States.[1] Sequela of cirrhosis and portal hypertension include varices, which occur in up to 60 to 80% of cirrhotic patients and pose a bleeding risk of 25 to 35%[2]; refractory ascites, which occurs in 5 to 10% of patients[3]; recurrent hepatic hydrothorax, which occurs in 5 to 10% of cirrhotic patients[4]; and hepatic encephalopathy, which occurs in up to 45% of patients with cirrhosis.[5] Transjugular intrahepatic portosystemic shunt (TIPS) creation results in portal venous decompression and reduces mortality and morbidity associated with these portal hypertensive sequelae. There is a clear survival benefit with TIPS creation in patients at risk of variceal hemorrhage, including those who fail endoscopic banding, who are at high risk of pharmacologic or endoscopic treatment failure,[6] and who undergo early TIPS creation for secondary prophylaxis against bleeding.[7] [8] For those with refractory ascites and hepatic hydrothorax, resolution of fluid accumulation can be expected in 85%[9] and 82%, respectively.[10]

Transvesicoscopic Ureteral Reimplantation for Primary Vesicoureteral Reflux in Children: Does Prior Failed Endoscopic Injection Impact Outcome?

Purpose: Transvesicoscopic ureteral reimplantation (TVUR) for vesicoureteral reflux (VUR) is a technically demanding operation. The technical difficulty is further increased by previous failed endoscopic injection, which causes intense fibrosis around the ureter. In this study, we compared primary TVUR with TVUR after previous failed endoscopic injection for VUR. Materials and Methods: The records of all children undergoing TVUR by a single surgeon over a 4-year period were analyzed. The children were divided into group 1 (primary TVUR, n = 50) and group 2 (TVUR after previous failed endoscopic treatment of Dextranomer/Hyaluronic Acid, n = 7). Demographic, clinical, radiologic, operative and follow-up data were compared between the two groups. The results were analyzed by statistical software; Mann-Whitney test and Fisher's exact test were used where appropriate, and P < .05 was considered significant. Results: Both the groups were comparable with respect to age and mean VUR grade. The mean VUR grade was significantly higher in group 1 and mean operative time per ureter was significantly more for group 2 than group 1. The postoperative hospital stay, success of TVUR, and complications were not significantly different between the groups. Conclusions: To our knowledge, this is the first report of its kind. TVUR after previous failed endoscopic injection could be done safely with good success, but with longer operative time than primary TVUR even in expert hands. Hence, previous failed endoscopic injection is not a contraindication to TVUR.

Endoscopy management of sleeve gastrectomy stenosis: what we learned from 202 consecutive patients.

Gastric sleeve stenosis (GSS) is described in 1%-4% of patients. To evaluate the role of endoscopy in the management of stenosis after laparoscopic sleeve gastrectomy using a standardized approach according to the characteristic of stenosis. Retrospective, observational, single-center study on patients referred from several bariatric surgery departments to an endoscopic referral center. We enrolled 202 patients. All patients underwent endoscopy in a fluoroscopy setting, and a systematic classification of the type, site, and length of the GSS was performed. According to the characteristics of the stenosis, patients underwent pneumatic dilatation or placement of a self-expandable metal stent or a lumen-apposed metal stent. Failure of endoscopic treatment was considered an indication for redo surgery, whereas patients with partial or complete response were followed up for 2 years. In the event of a recurrence, a different endoscopic approach wasused. We found inflammatory strictures in 4.5% of patients, pure narrowing in 11%, and functional stenosis in 84.5%. Stenosis was in the upper tract of the stomach in 53 patients, whereas medium and distal stenosis was detected in 138 and 11 patients, respectively, and short stenosis in 194 patients. A total of 126 patients underwent pneumatic dilatation, 8 self-expandable metal stent placement, 64 lumen-apposed metal stent positioning, and 36 combined therapy. The overall rate of endoscopy success was 69%. GSS should be considered to be a chronic disease, and the endoscopic approach seems to be the most successful treatment, with a prolonged positive outcome of 69%. Characteristics of thestenosis should guide the most suitable endoscopic approach.

Risk factors associated with failure of endoscopic combined treatment to prevent varices rebleeding in patients with liver cirrhosis

ABSTRACT Background The aim of this study is to investigate risk factors associated with gastroesophageal variceal rebleeding after endoscopic combined treatment. Research design and methods Patients who had liver cirrhosis and underwent endoscopic treatment to prevent variceal rebleeding were retrospectively recruited. Hepatic venous pressure gradient (HVPG) measurement and CT examination of portal vein system were performed before endoscopic treatment. Endoscopic obturation for gastric varices and ligation for esophageal varices were performed simultaneously at the first treatment. Results One hundred and sixty-five patients were enrolled, and after the first endoscopic treatment, recurrent hemorrhage occurred in 39 patients (23.6%) during 1-year follow-up. Compared to the non-rebleeding group, HVPG was significantly higher (18 mmHg vs.14 mmHg, P = 0.024) and more patients had HVPG exceeding 18 mmHg (51.3% vs.31.0%, P = 0.021) in the rebleeding group. No significant difference was found in other clinical and laboratory data between two groups (P > 0.05 for all). By a logistic regression analysis, high HVPG was the only risk factor associated with failure of endoscopic combined therapy (OR = 1.071, 95%CI, 1.005–1.141, P = 0.035). Conclusions The poor efficacy of endoscopic treatment to prevent variceal rebleeding was associated with high HVPG. Therefore, other therapeutic options should be considered for the rebleeding patients with high HVPG.

Long-Term Results of Endoscopic Metal Stenting for Biliary Anastomotic Stricture after Liver Transplantation.

(1) Background: Anastomotic biliary stricture (ABS) is a well-known complication of liver transplantation which can lead to secondary biliary cirrhosis and graft dysfunction. The goal of this study was to evaluate the long-term outcomes of endoscopic metal stenting of ABS in the setting of deceased donor liver transplantation (DDLT). (2) Methods: Consecutive DDLT patients with endoscopic metal stenting for ABS between 2010 and 2015 were screened. Data on diagnosis, treatment and follow-up (until June 2022) were collected. The primary outcome was endoscopic treatment failure defined as the need for surgical refection. (3) Results: Among the 465 patients who underwent LT, 41 developed ABS. It was diagnosed after a mean period of 7.4 months (+/-10.6) following LT. Endoscopic treatment was technically successful in 95.1% of cases. The mean duration of endoscopic treatment was 12.8 months (+/-9.1) and 53.7% of patients completed a 1-year treatment. After a mean follow-up of 6.9 years (+/-2.3), endoscopic treatment failed in nine patients (22%) who required surgical refection. Conclusions: Endoscopic management with metal stenting of ABS after DDLT was technically successful in most cases, and half of the patients had at least one year of indwelling stent. Endoscopic treatment long-term failure rate occurred in one fifth of the patients.

Optimizing decision-making process of benign uretero-enteric anastomotic stricture treatment after radical cystectomy.

To identify preoperative predictors of endo-urological treatment (EUT) failure while promoting a new diagnostic and therapeutic pathway for benign uretero-enteric anastomosis stricture (UES) management after radical cystectomy (RC). We relied on a prospectively maintained database including 96 individuals (122 renal units) who developed a benign UES at our institution between 1990 and 2018. UES was classified into two different types according to morphology: FP1 (i.e., sharp or duckbill) and FP2 (i.e., flat or concave). EUT feasibility, success rate, as well as intra and postoperative complications were recorded. Uni- and multivariable logistic regression analysis (MVA) assessed for predictors of EUT failure. Overall, 78 (63.9%) and 32 (26.3%) cases were defined as FP1 and FP2, respectively. EUT was not feasible in 33 (27.1%) cases. After a median follow-up of 50 (IQR 5-240) months, successful treatment was reached only in 15/122 (12.3%) cases. EUT success rates raised when considering short (< 1cm) (16.8%), FP1 morphology (16.7%) strictures, or the combination of these characteristics (22.4%). Overall, 5 (5.2%) cases had CD ≥ III complications. FP2 (OR: 1.91, 95%CI 1.21-5.31, p = 0.03) and stricture length ≥ 1cm (OR: 9.08, 95%CI 2.09-65.71, p = 0.009) were associated with treatment failure at MVA. Endoscopic treatment for benign UES after RC is feasible but harbors a low success rate. Stricture length and radiological morphology of the stricture are related to endoscopic treatment failure. Surgeons should be aware of the stricture features during the preoperative decision-making process to choose the optimal candidate for endoscopic treatment.

CHALLENGING THE DOGMAS: LAPAROSCOPIC COMMON BILE DUCT EXPLORATION THROUGH DIATHERMY, CHOLEDOCHOTOMY AND PRIMARY CLOSURE. LONG TERM OUTCOMES IN A REFERRAL CENTER

Abstract Introduction Choledocholithiasis is a frequent pathology, unfortunately when its endoscopic management fails there is no consensus on how it should be addressed. The aim of this study was to evaluate the safety, feasibility and long-term outcomes of laparoscopic common bile duct exploration (LCDBE) using electrosurgery (coagulation) for choledochotomy followed by primary closure after endoscopic treatment failure. Methods A retrospective cohort of 168 patients who underwent LCDBE from 2013 to 2018 which was conducted all by choledochotomy. Clinical demographics, operative outcomes, recurrence rate of CBD stones, and long-term bile duct complications were analyzed. Results The male/female ratio was 90/78 and mean age was 73 years. Stone clearance was successful in 167 patients (99.4%). Nonlethal complications were noted in 3 patients during the surgery or in the immediate postoperative (1.79%) and managed with T-tube or endoscopically. No cases of surgery-related mortality were observed. There were no signs of any type of biliary injury or stricture observed in any of the patients during the 24-month follow-up period. Conclusions LCBDE through choledochotomy with diathermy and primary closure can be performed without increased risk of operative complications such as important and visual-impairment bleeding as well as long-term complications such as bile duct stricture or recurrent CBD stones. LCBDE with diathermy and primary closure is a safe and effective treatment option for choledocholithiasis for failed ERCP in terms of long-term outcome as well as short-term outcome.

Esophageal stent placement for endoscopic treatment failure.

Up until approximately 10 years ago, the treatment for acute refractory esophageal variceal bleeding was balloon tamponading. Esophageal fully covered self-expanding stents are considered as effective as balloons and also much safer. They are kept in situ for longer periods, what eases the access to more definitive treatments with a low complication rate. We present 6 cases of patients with cirrhosis and massive bleeding due to esophageal varices refractory to conventional treatment, successfully treated with an esophageal fully covered self-expanding stent. There were no major complications, achieving an effective bleeding control in all cases.

Long-Term Outcomes of Laparoscopic Common Bile Duct Exploration Through Diathermy, Choledochotomy, and Primary Closure: A 6-Year Retrospective Cohort Study.

Background and Objective: Choledocholithiasis is a frequent pathology, unfortunately when its endoscopic management fails, there is no consensus of how it should be addressed. The aim of this study was to evaluate the safety, feasibility, and long-term outcomes of laparoscopic common bile duct exploration (LCBDE) using electrosurgery (coagulation) for choledochotomy followed by primary closure after endoscopic treatment failure. Materials and Methods: A retrospective cohort study of patients who underwent LCBDE from 2013 to 2018 was conducted in Bogotá, Colombia. Clinical demographics, operative outcomes, recurrence rate of common bile duct stones, and long-term bile duct complications were analyzed. A descriptive analysis was performed. Results: A total of 168 patients were analyzed. Most of the patients were males (53.37%) with a median age of 73 years with no comorbidities (65%). Stone clearance was successful in 167 patients (99.4%). Nonlethal complications were noted in 3 patients during the surgery or in the immediate postoperative (1.79%) and managed with T-tube or endoscopically. No cases of mortality surgery related were observed. There were no signs of any type of biliary injury or stricture observed in any of the patients during the 24-month follow-up period. Conclusions: LCBDE with diathermy and primary closure is a safe and effective treatment option for choledocholithiasis for failed endoscopic retrograde cholangiopancreatography in terms of long-term outcome as well as short-term outcome.

S3731 A Rare Complication of Peptic Ulcer Disease: Double Pylorus Syndrome

Introduction: Double Pylorus Syndrome or gastroduodenal fistula is a rare entity usually found incidentally on endoscopy. This syndrome can be congenital or secondary to gastric malignancy or peptic ulcer disease. The pylorus has two openings which connect the duodenal bulb to the gastric antrum. This syndrome is extremely rare and found in less than .5% of cases. Recurrent gastrointestinal (GI) bleeding can occur secondary to inadequate epithelization of the tract and recurrent ulcerative disease. We present a unique consequence of peptic ulcer disease in a 68 year old female found to have Double Pylorus Syndrome. Case Description/Methods: A 68 year-old female with PMH of atrial fibrillation on anticoagulation presented to the hospital for evaluation of iron deficiency anemia and was found to have a hemoglobin of 6.8. She was treated with an intravenous proton pump inhibitor drip and iron supplementation. Iron studies revealed an iron level was 19 with a ferritin of 11. She had undergone prior upper endoscopic evaluation which revealed a non-bleeding gastric ulcer in the antrum. She underwent repeat esophagogastroduodenoscopy which revealed a duodenal ulcer with active oozing which was treated with epinephrine, two endoclips, and gold probe electrocautery. A double pylorus was also seen. The patient was discharged with a course of PPI therapy and was cleared to resume anticoagulation, however, she deferred restarting until discussion with her outpatient cardiologist. (Figure) Discussion: Our case represents an acquired form of Double Pylorus Syndrome (Image 1) which is a rare complication of peptic ulcer disease. Acquired gastro-duodenal fistulas are uncommon and typically present in the prepyloric region in combination with chronic peptic ulcer disease as seen with our patient. This type of fistula forms due to inflammation of the gastric gastric antrum or duodenal bulb leading to adhesions that form between the gastric and duodenal walls. Standard treatment is with a proton pump inhibitor, avoiding triggers such as NSAIDs and corticosteroids, and eliminating H. pylori if present. Our patient responded well to medical management. Surgical intervention is necessary if there are refractory symptoms, perforation, or failure of endoscopic treatment. We present a rare anatomical entity secondary to peptic ulcer disease that clinicians should be aware of and thus be vigilant in treating the underlying cause.Figure 1.: Double Pylorus.