Endoscopic Closure of a Postoperative Duodenal Fistula

Tammy L. Kindel, MD, PhD, Caitlin A. MacGregor, BA, Rajesh N. Keswani, MD, David M. Mahvi, MDDepartment of Surgery (Drs. Kindel, MacGregor, Mahvi) and Department of Medicine (Dr. Keswani), Northwestern University Feinberg School of Medicine, Chicago, IL, USA.

ABSTRACTIntroduction: Bouveret syndrome is a rare presentation of gallstone ileus characterized by passage of a gallstone through a cholecystoenteric fistula and impaction of the gallstone within the duodenum, causing proximal small bowel obstruction. Most patients require surgery with duodenotomy and stone extraction. Unfortunately, duodenal surgery has a high risk for surgical complications, including suture-line leaks and fistula formation. Fistulas that fail to close with conservative management, and those complicated by electrolyte and fluid disturbances, require surgical correction. Recently, over- the-scope clip devices have been used successfully for enteric fistula closure.

Case Description: We present the case of a 33-year-old man with a postsurgical duodenal leak after duodenorrhaphy as surgical treatment for Bouveret syndrome. Two weeks after surgery, the patient underwent successful over-the-scope clip closure of a high-output duodenal fistula, requiring no subsequent endoscopic or operative fistula management.

Discussion: Over-the-scope clips appear promising for successful closure of postsurgical duodenal fistulas that persist despite conservative management and optimized nutritional status.

Key Words: Duodenal fistula, Over-the-scope clip, OTSC, Bouveret syndrome, Fistula closure.

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