DEFINITIVE PYLORIC CLOSURE FOR TREATMENT OF DIGESTIVE FISTULA AFTER PANCREATODUODENECTOMY WITH OVER-THE-SCOPE CLIP (PADLOCK)

Fechamento pilórico definitivo para o tratamento da fístula digestiva após pancreato-duodenectomia com clipe “over-the-scope” (Padlock)

The endoscopic treatment of gastrointestinal perforations or digestive fistulas using endoclips dates from 1997 and represents a minimally invasive and effective therapeutic alternative associated with lower morbidity and mortality rates than conventional surgical approaches^1,2. In 2009, the “over-the-scope-clip” system emerged as a new tool that would facilitate complete circumferential closure of tissues via endoscopy^3-5. Pinho R et al., in 2015, described the first application of the “over-the-scope-clip” in endoscopic pyloric exclusion, performed after an unsuccessful attempt of surgical treatment of an intestinal fistula⁶.

We present a video of a definitive pyloric exclusion for the treatment of intestinal fistula using the Padlock “over-the-scope-clip” after pancreatoduodenectomy (PD). This is the second report of this technique and the first video demonstrating the procedure (^E-VIDEO*).

Seventy-six-y-old male, with previous robotic hepatectomy, who underwent PD and partial hepatectomy for pancreatic ductal adenocarcinoma, having previously undergone neoadjuvant chemotherapy. Liver resections were performed for suspected secondary impairment but demonstrated only inflammatory lesions (abscesses). Two months after the surgery, the patient developed nausea and frequent vomiting, in addition to multiple episodes of bronchoaspiration, requiring several digestive endoscopies and the passage of a nasojejunal tube Freka^® Trelumina. Given the refractoriness of the condition, surgical treatment with mechanical Y-de-Roux gastroenteroanastomosis and drain placement were chosen. Two weeks after the intervention, on abdominal computed tomography scan, small gaseous foci were identified in the upper abdomen, mainly adjacent to the drain (Figure 1). An upper digestive endoscopy was performed and disclosed a perforation on the afferent biliopancreatic limb close to the duodenojejunal anastomosis performed on the PD, compatible with late fistula. After 7 days of the endoscopic examination, closure and exclusion of the pylorus was performed with the use of two Padlock (Figure 2). Contrast examination (barium meal) was performed 1 week after the procedure, showing no leakage of contrast or fistulous pathways and effective pyloric exclusion (Figure 2B). At revision upper digestive endoscopy, a wide and patent gastroenteroanastomosis was observed with total closure of the pylorus. The patient presented uneventful recovery from the pyloric exclusion and returned to oral feeding.

FIGURE 1
Intravenous contrast enhanced abdominal computed tomography disclosing small liquid collection with air foci (yellow arrows) suggestive of digestive fistula close to the hepatic raw surface area. A) Axial plane; B) Sagital plane.

FIGURE 2
A) Pyloric exclusion with Padlock “over-the-scope-clip”; B) Barium meal disclosing the Padlocks, no contrast leakage, effective exclusion of the pylorus and patent gastroenteroanastomosis.

This is the second report on literature of pyloric exclusion with “over-the-scope-clip”, reassuring the safety and effectiveness of the technique. It is a less invasive alternative and with lower morbidity than performing revision surgeries in order to treat digestive fistulae. Its use should be considered as an option to perform pyloric exclusion for different indications of the procedure.

REFERENCES

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• *
  E-VIDEO: https://youtu.be/s563aO_zV4w

• Disclosure of funding: no funding received

Publication Dates

• Publication in this collection
  22 Oct 2021
• Date of issue
  Jul-Sep 2021

History

• Received
  19 Feb 2021
• Accepted
  15 Mar 2021