Video
Pancreatico-colonic fistula closure.
Introduction
Pancreatic pseudocyst is a known local adverse event of pancreatitis. Spontaneous pseudocyst fistulization occurs in approximately 3% of cases. Fistulas to the stomach or small bowel can spontaneously drain fluid collections and do not necessarily require closure. In contrast, pancreatico-colonic fistulas (PCFs) can be associated with hemorrhage and persistent infection, which warrant more definite management. Traditionally, surgical approaches like segmental resection or diverting ileostomy were pursued. More recently, endoscopic PCF closure with fibrin glue or clips has been reported with favorable outcomes. Use of over-the-scope clips (OTSC) for PCF closure has rarely been reported.1, 2, 3, 4
Case Description and Methods
A 31-year-old man with autoimmune hepatitis presented with abdominal pain and fevers. He had a history of gallstone pancreatitis 1 year prior, complicated by recurrent necrotizing pancreatitis with infected peripancreatic necrotic fluid requiring percutaneous drainage at the index admission because of lack of mature wall. On admission, he was febrile. A CT scan of the abdomen with contrast showed inflammatory changes near the pancreatic head with multiple loculated peripancreatic collections (Fig. 1). Fluoroscopy-guided cystogram through an existing pigtail drain showed filling of the fluid collections with a fistulous connection to the colon (Fig. 2). Cyst aspirate and blood cultures were positive for Enterococcus faecalis. Endoscopic PCF closure was pursued because of persistent bacteremia.
Figure 1.
Multiple peripancreatic fluid collections on CT scan.
Figure 2.
Cystogram showing a fistulous connection with the colon.
On colonoscopy, 2 fistulas with 3-mm openings were identified at the hepatic flexure by injection of normal saline mixed with methylene blue into the percutaneous drain and visualization of the injectate in the colon (Fig. 3). The fistulas were successfully closed using 12/6t OTSC (OVESCO Endoscopy AG, Tübingen, Germany). The “type t” clips provide adequate anchoring and compression effect for colonic closure. A larger-sized clip would have probably been unnecessary and would have resulted in some difficulty with insertion, while a smaller-sized clip could have been less likely to be successful. The Twi Graspers (OVESCO Endoscopy AG) were used to assist with closure of one of the fistulas because of difficulty achieving en face positioning, to ensure the fistula opening remained at the center of the cap.
Figure 3.
Fistula identification.
The bacteremia and sepsis resolved, and the overall status markedly improved. The drain output was monitored daily during hospitalization. The drains were periodically exchanged or repositioned by interventional radiology and were removed 3 weeks after PCF closure (2 months after initial placement) after sustained lack of output and fluoroscopy-guided imaging showing small residual cavities. The patient completed a 4-week course of antibiotics, which was stopped 2 weeks after resolution of bacteremia. A CT scan 2 months later showed marked improvement in the fluid collection and inflammation along with a sustained improvement of the overall status (Fig. 4). At the 4-month follow-up visit, he reported resolution of the abdominal pain and anorexia and restoration of physical activity.
Figure 4.
Improvement in fluid collection on a follow-up CT scan.
Discussion
In this case, endoscopic closure was pursued because there was suspicion of colonic contamination leading to persistent bacteremia. This PCF case was suitably managed endoscopically with OTSC, leading to resolution of bacteremia and clinical improvement. PCF closure is not always technically feasible in cases of numerous fistulous openings or unamenable colonic mucosa. Guidelines on the nonsurgical indications and optimal endoscopic approach to PCF closure have not been established, and close follow-up with possible repeated interventions may be necessary. Multidisciplinary care is essential because surgical management may be warranted if infection control is not achieved (Video 1, available online at www.videogie.org).
Disclosure
The authors disclosed no financial relationships relevant to this publication.
Supplementary data
Pancreatico-colonic fistula closure.
References
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Associated Data
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Supplementary Materials
Pancreatico-colonic fistula closure.
Pancreatico-colonic fistula closure.