Novel use of endoscopic pyloric exclusion and diverting gastrojejunostomy in a patient with duodenal-renal-colonic fistula

Video

Video 1

EUS-guided gastrojejunostomy and pyloric exclusion for a duodenal-renal-colonic fistula.

Case Presentation

A 55-year-old man with a history of stage 4 sarcomatoid renal cell cancer was admitted with dizziness, hypotension, and 3 weeks of diarrhea. CT imaging showed a 13-cm mass originating from the right kidney with extension into the duodenum and ascending colon (Fig. 1). The patient was deemed to be a nonsurgical candidate because of comorbidities and vascular involvement of the tumor. An upper GI series with small-bowel follow-through study showed passing of oral contrast from the duodenum into the tumor cavity and then directly to the ascending colon without filling of the downstream duodenum. To allow the patient to continue oral intake and to minimize debilitating diarrhea, we elected to perform a diverting EUS-guided gastrojejunostomy (GJ) bypass and pyloric exclusion of the duodenal fistula with palliative intent.

Figure 1.

CT image showing an approximately 13-cm tumor mass invading the inferior pole of the right kidney. Inflammatory changes around the ascending colon and duodenal area are visible.

Procedure Details

Preprocedural prophylactic antibiotics were administered. After advancing the endoscope past the duodenal bulb, a large stool collection and downstream obstruction was identified. Contrast instillation filled the tumor cavity and ascending colon but not the downstream duodenum. Guidewire exploration showed complete obstruction of the downstream duodenum. To bypass the obstruction, we performed EUS-guided GJ via the needle insufflation technique as opposed to the traditional approach.¹ Linear echoendoscope was advanced into the stomach, and the large right renal mass/second portion of the duodenum was identified sonographically. The downstream, decompressed duodenum was followed endosonographically to a portion of proximal jejunum adjacent to the gastric wall. A 19-gauge FNA needle was used to puncture the collapsed jejunal lumen transgastrically. The initial injection appeared to be extraluminal with contrast layering around the small bowel in the peritoneum. Ultimately, the needle was advanced into the lumen, and injection of contrast confirmed placement. Saline was then instilled via the needle to distend the jejunum. Of note, no retrograde filling of the duodenal-renal-colonic fistula was seen fluoroscopically. After distention, the initial puncture site was not suitable for creating the anastomosis owing to the angulation. We identified a loop of downstream jejunum adjacent to the stomach that was much easier to approach. A 20- × 10-mm cautery-enhanced lumen-apposing metal stent (LAMS) was advanced freehand into the jejunum and deployed. The LAMS was then balloon dilated to 18 mm to facilitate expansion and apposition (Fig. 2).

Figure 2.

Lumen-apposing metal stent placement in the gastric cavity.

The echoendoscope was then exchanged for a double-channel gastroscope with an endoscopic suturing device. The pylorus was targeted with a total of 4 interrupted sutures in a perpendicular fashion (anterior-posterior and lesser curvature–greater curvature) in 2 layers and cinched closed. A tissue helix was used to obtain a full-thickness “bite.”

The following day, an upper GI series with small-bowel follow-through was obtained, confirming closure of the pylorus with diversion at the newly created GJ (Fig. 3). After the procedure, the patient was able to advance to a regular diet by day 3, and the severity of diarrhea improved to 1 loose stool daily at the first-month follow-up. The decision was made to leave the LAMS in place permanently to reduce procedural burden for the patient.

Figure 3.

Fluoroscopic images before (A) and after (B) EUS-guided gastrojejunostomy and pyloric exclusion procedure.

Discussion

Reno-colonic fistulas are a rare adverse event of metastatic renal cell cancer with reported presentations of GI bleeding, septic shock, pneumaturia, and emphysematous pyelonephritis.2, 3, 4 Pyloric exclusion (PEX) initially evolved as a surgical procedure first reported in 1977 to address duodenal injuries.⁵ As endoscopic capabilities developed, endoscopic PEX was first reported using over-the-scope clips and subsequently endoscopic suturing devices.6, 7, 8, 9 Here we report a case of malignant duodenal-renal-colonic fistula uniquely treated with combined EUS-guided GJ and PEX. Given the nascency of this procedure, limited data on efficacy, long-term durability, and safety are available, and prospective studies are needed (Video 1, available online at www.videogie.org).

Disclosure

Dr Azeem is a consultant for Boston Scientific. The other authors disclosed no financial relationships relevant to this publication.

Supplementary data

Video 1

EUS-guided gastrojejunostomy and pyloric exclusion for a duodenal-renal-colonic fistula.

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