Endoscopic treatment of duodenal fistula after incomplete closure of ERCP-related duodenal perforation

Abstract

Endoscopic retrograde cholangiopancreatography (ERCP) is an important diagnostic and therapeutic modality for various pancreatic and biliary diseases. The most common ERCP-induced complication is pancreatitis, whereas hemorrhage, cholangitis, and perforation occur less frequently. Early recognition and prompt treatment of these complications may minimize the morbidity and mortality. One of the most serious complications is perforation. Although the incidence of duodenal perforation after ERCP has decreased to < 1.0%, severe cases still require prolonged hospitalization and urgent surgical intervention, potentially leading to permanent disability or mortality. Surgery remains the mainstay treatment for perforations of the luminal organs of the gastrointestinal tract. However, evidence from case reports and case series support a beneficial role of endoscopic clipping in the closure of these defects. Duodenal fistulas are usually a result of sphincterotomies, perforated duodenal ulcers, or gastrectomy. Other causative factors include Crohn’s disease, trauma, pancreatitis, and cancer. The majority of duodenal fistulas heal with nonoperative management. Those that fail to heal are best treated with gastrojejunostomy. Recently proposed endoscopic approaches for managing gastrointestinal leaks caused by fistulas include fibrin glue injection and positioning of endoclips. Our patient developed a secondary persistent duodenal fistula as a result of previous incomplete closure of duodenal perforation with hemoclips and an endoloop. The fistula was successfully repaired by additional clipping and fibrin glue injection.

Keywords: Perforation, Duodenal, Endoscopic retrograde cholangiopancreatography, Fistula, Glue

Core tip: In this report, a patient developed a secondary persistent duodenal fistula following an incomplete endoscopic closure of endoscopic retrograde cholangiopancreatography-related duodenal perforation with hemoclips and an endoloop. The fistula was successfully managed by further endoscopic treatment with additional clipping and fibrin glue injection. This case emphasizes that endoscopists should remain aware of the possibility for a secondary persistent fistula formation due to incomplete closure when long-standing fluctuating free air is detected after endoscopic treatment of bowel perforation.