Toufic Kachaamy, MD, from the Western Regional Medical Center at Cancer Treatment Center of America, Goodyear, Arizona, USA, present this video case “Endoscopic management of a gastrocolonic fistula.”
A 55-year-old man presented with dysphagia secondary to esophageal adenocarcinoma. He underwent an esophageal stent placement with significant improvement in his dysphagia. His esophageal stent migrated a month later and he was admitted with sepsis. His stent was removed and he was treated with antibiotics. He was eventually discharged home but started having intractable diarrhea of unclear etiology and became severely malnourished. He presented to our center for a second opinion. An upper endoscopy showed a large gastrocolonic fistula which was the cause of the diarrhea. The fistula was likely caused by the stent eroding through the stomach wall into the colon. Given his advanced cancer and his malnutrition, he was a poor surgical candidate so endoscopic repair was attempted. Repair was done by ablation of any mucosa in the fistula track and multilayer closure with suturing and over the scope clipping. The patient had over 20 kg weight gain in the following two months and a significant improvement in his quality of life. He was able to resume systemic chemotherapy for which he initially responded.
Figure 1. A, The gastrocolonic fistula seen from the stomach. B, Fistula tract being ablated from the colonic side. C, Fistula closed on follow up.
This case highlights a rare but important adverse event of esophageal stenting caused by stent migration and erosion through the gastric wall. It also demonstrates the concept of multilayer closure of gastrointestinal defects. Gastrointestinal fistula in cancer patient are very difficult to manage endoscopically. Multilayer closure might increase the chance of fistula healing especially the ones that are non-malignant as in this case.
The concept of multilayer closure involves initial closure of the defects and subsequent approximation of the tissue above and below the defect to decrease tension from the middle layer and decrease the risk of dehiscence. This is especially important in cancer patients who are malnourished as their risk of dehiscence is very high.
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