Post written by Gustavo de Carvalho Bertaccini Guriam, MD, MSc, from the Department of Endoscopy, São Francisco Hapvida Hospital, São Paulo, Brazil.

This case describes successful closure of a complex duodenal fistula that failed to respond to 2 surgical attempts at local suture after major abdominal surgery. Definitive treatment was achieved through a multimodal endoscopic approach, including modified endoscopic vacuum therapy (EVT), endoscopic internal drainage (EID), and final closure with an over-the-scope clip (OTSC). The combination of these techniques allowed for progressive cavity collapse, continuous drainage, and definitive tissue approximation, thereby avoiding the need for further surgical intervention.

Duodenal fistulas are serious adverse events that frequently necessitate surgical intervention because of their association with significant morbidity and mortality. However, recent advances in therapeutic endoscopy have provided effective, minimally invasive alternatives. This case highlights successful management of a complex duodenal fistula through stepwise application of 3 complementary endoscopic techniques: modified EVT, internal drainage with double-pigtail stents, and OTSC closure. The sequential use of these modalities enabled progressive control of the fistulous tract, cavity collapse, and definitive sealing of the orifice. By illustrating the synergistic effect of a multimodal endoscopic approach, this video offers practical insights for advanced endoscopists facing similarly challenging scenarios.

Endoscopists can appreciate the benefit of sequential, patient-tailored intervention using multiple techniques. In this case, use of modified EVT with nasocavity suction, followed by EID and final closure with an OTSC, proved essential for addressing internal and external components of the leak. The association of internal drainage with EVT was particularly significant: Beyond facilitating drainage of purulent material from the cavity into the duodenal lumen, the pigtail stent enhanced local debridement and allowed direct propagation of negative pressure to the fistulous tract, thereby stimulating tissue granulation and healing. Furthermore, continuous contact between the stent and perforated mucosa promoted localized ulceration, which contributed to mucosal remodeling and closure.

An additional benefit of the pigtail stent was its role in guiding antimicrobial therapy. Upon removal, it enabled bacterial culture of the cavity contents, which identified 2 multidrug-resistant organisms. This information permitted targeted antibiotic adjustment, leading to resolution of the patient’s persistent fever. Altogether, this case illustrates not only the therapeutic synergy of combining advanced endoscopic techniques but also the importance of multidisciplinary collaboration and structured endoscopic follow-up in managing complex GI fistulas.

To our knowledge, this is one of the few reports demonstrating successful stepwise combination of EVT, EID, and an OTSC in managing a refractory duodenal fistula. This case may serve as a reference for endoscopists considering endoscopic salvage therapy for surgical leaks.

A, Periduodenal cavity with a stent for internal drainage and granulation tissue highlighted by the black arrow. B, Red arrow highlights the ulcer between the stent and the duodenal mucosa.

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