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Endoscopic clipping of a colocutaneous fistula following necrotizing pancreatitis: case report
Digestive and Liver Disease 35 (2003) 907–910
Brief Clinical Observation
Endoscopic clipping of a colocutaneous fistula following necrotizing pancreatitis: case report P. Familiari a,∗ , A. Macr`ı a , P. Consolo b , L. Angiò a , M.G. Scaffidi b , C. Famulari a , L. Familiari b a b
Emergency Surgery Unit, University of Messina, Messina, Italy Digestive Endoscopy Unit, University of Messina, Messina, Italy Received 11 November 2002; accepted 10 May 2003
Abstract The case described here is of a 73-year-old male patient who developed a colocutaneous fistula following necrotizing pancreatitis, diagnosed by imaging and treated endoscopically by the application of an endoclip. Pancreatic and gastrointestinal fistulas, common complications of surgery for necrotizing pancreatitis, frequently require surgical treatment. Colonic perforations are the most difficult to treat surgically on account of the risk of peritonitis. A technique, namely, endoscopic clips application, has recently been developed to close anastomotic leakages and perforations of the oesophagus, stomach and colon. In the patient described here, endoscopic repair was technically easy and the good result was confirmed within a few days. In order to repair colonic fistulas following pancreatitis, application of endoclips could, in our opinion, provide a useful therapeutic option, feasible in selected patients. © 2003 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved. Keywords: Colonic fistula; Endoclip; Pancreatitis
1. Introduction The endoscopic application of clips is a routine technique for the emergency treatment of gastrointestinal bleeding [1], and has recently been employed in the treatment of anastomotic leakages and, especially, iatrogenic perforations of the oesophagus [2–4], stomach [1] and colon [5]. It is used primarily in the case of perforation due to snare resection of large colonic polyps or to endoscopic mucosectomy [6]. Colocutaneous fistulas require surgical treatment [7], colostomy, surgical resection of the drained colon and later re-anastomosis [8]. We report here a patient who developed a colocutaneous fistula, lately after a surgical phase for necrotizing pancreatitis, that was treated conservatively. 2. Case report A 73-year-old male patient, submitted to surgery for necrotizing pancreatitis, was rehospitalised 60 days later, ∗ Corresponding author. Tel.: +39-090-2212773; fax: +39-090-2921929. E-mail address: [email protected] (P. Familiari).
Fig. 1. Percutaneous fistulography. Fistula is visible between median transverse colon and skin surface. Small arrow: drainage catheter; thick arrow: contrast filling colon.
1590-8658/$30 © 2003 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.dld.2003.05.001
908
P. Familiari et al. / Digestive and Liver Disease 35 (2003) 907–910
complaining of diffuse abdominal pain, fatigue and fever rising to 38 ◦ C in the evening. The surgical procedure consisted of debridement of the infected necrotic areas of the pancreas (head and body), evacuation of peripancreatic fluid collections and multiple drainage tubes associated with cholecystectomy. The patient had been discharged on the 30th post-operative day with two drainage catheters (at the root of the gastrocolic and duodenocolic ligaments and in the left paracolic gutter), which were left in situ on account of the secretion of small amounts of a sieropurulent exudate. At follow-up, in the outpatient unit, the patient was medicated for the drainages. Upon re-admission, physical examination of the abdomen revealed a slight tenderness in the lower quadrants. Routine
blood tests revealed abnormal levels of alkaline phosphatase (1028 IU/l), gamma glutamyl transferase (␥-GT) (263 IU/l), alanine transferase (ALT) (79 IU/l), cholinesterase (1818 IU/l), moderate leukocytosis (10,700/l) and anaemia (red blood cells (RBC) 380,000/l). Leakage of pus and necrotic material from the drainage tubes was observed and at the upper right abdominal quadrant, where another drainage catheter had previously been placed, a fistula 5 mm in diameter secreting enteric-like fluid was present. Percutaneous fistulography was performed, which revealed the presence of a fistula between the median transverse colon and the skin surface; another small fistula was detected in the descending colon which presented
Fig. 2. (a) Endoscopic view of fistula in transverse colon with a guide-wire inserted for easier identification; (b) closure of fistula with clip; (c) endoscopic control 11 days later.
P. Familiari et al. / Digestive and Liver Disease 35 (2003) 907–910
leakage of contrast medium, which was collected by the drainage catheter adjacent to the left colonic wall; the catheter was withdrawn, under fluoroscopic control, for 2 cm (Fig. 1). Abdominal CT scan revealed small collections of fluid on the anterior surface of the pancreas, in the anterior fascia of the kidney, in the pancreatic–splenic ligament and at the hilus of the liver, which, compared to previous examinations, definitely showed signs of regression and, moreover, revealed the presence of a drainage tube inside the transverse colon. Low-pressure Gastrographin® (Schering AG, Berlin, Germany) enema led to retrograde opacification of the drainage catheter localized in the transverse colon, without revealing any leakage from the descending colon. Colonoscopy revealed, in the medium part of the transverse colon, a 6 mm mucosal break, through which the drainage tube had passed. After establishing the diameter of the fistula and the good trophism of the peripheral mucosa, conservative treatment was carried out with the application of an endoscopic clip (Fig. 2a). Then, using a 0.035 in. (0.88 mm) guide-wire, the drainage catheter was withdrawn from the colon and a metal clip (Olympus MD 850, Olympus Europe, Hamburg, Germany) estimated to be suitable to stop the leakage was applied. The guide-wire was removed and drainage of pus and infected fluid from the catheter stopped (Fig. 2b). The patient was submitted to total parenteral nutrition for 7 days. On the 11th day, colonoscopy confirmed complete closure of the fistula and the patient was discharged (Fig. 2c). The two drainage tubes were removed on the 16th day. On the 30th day, control enema confirmed repair of the fistula (Fig. 3). Moreover, CT, performed 5 months later, did not reveal any lesion in the pancreas or surrounding areas and no pathological fluid collections were detected in the abdomen.
Fig. 3. Control enema at 30th day confirmed repair of fistula.
909
3. Discussion Pancreatic and gastrointestinal fistulas are common complications following surgery for infected necrotizing pancreatitis; furthermore, the incidence, in the literature, ranges from 10 to 41% [7–11]. These complications are likely related to parietal necrosis provoked by the combined effect of local ischaemia, due to small-vessel thrombosis and enzymatic digestion [7]; a direct injury caused by the drainage tubes has also been hypothesized. Development of external colonic fistulas often follows the surgical drainage of the pancreas. Colonic fistulas often need surgical repair, such as simple suture closure, protective colostomy, or even resection with anastomosis, which implicates a high morbidity and mortality risk for the patient [8–10]. First described exclusively for emergency haemostasis of gastrointestinal bleeding, the endoscopic application of clips was performed, in 1993, by Binmoeller et al. for the treatment of iatrogenic gastric perforation [1]. Since then, several cases of iatrogenic perforations of the oesophagus, stomach and colon, following polypectomy, mucosectomy, biliary stent dislocation, endoscopic pneumatic dilation or accidental perforations due to removal of foreign bodies, have been successfully treated with the use of the endoscopic clip [2–5,12–14], such as closure of anastomotic leaks following oesophago-gastric surgery [15]. In the case reported here, endoscopic repair, by clip application, was necessary due to a colocutaneous fistula which developed after necrosectomy and introduction of drainage tubes in a patient with infected necrotizing pancreatitis. The endoscopic repair of the leak was technically easy; the fistula was rapidly identified and one clip was sufficient to achieve a good result with healing of the orifice in a few days. During follow-up, 5 months later, diagnostic examinations confirmed the successful outcome both of the pancreatic inflammation and the colonic fistula. The success of the endoscopic clip in the management of a fistula has been generally recognized, the success depending on several factors, such as its size, the time elapsing between development of the fistula and treatment and patient’s otherwise good state of health; diffused peritonitis or necrosis at the borders of the leakage and peripheral tissues advise against conservative treatment of the fistula [12]. Since in our patient the fistula was small in size, the colonic mucosa around it was in a good condition and clinical presentation was late, these data led us to consider the development of the lesion as iatrogenic, due to perforation caused by the drainage catheter. In conclusion, even though no generalized treatment can be defined, at present, the application of endoclips in the repair of colonic fistulas following pancreatitis could provide a new worthwhile therapeutic option, feasible in properly selected patients.
910
P. Familiari et al. / Digestive and Liver Disease 35 (2003) 907–910
Conflict of interest statement None declared. Acknowledgements Authors thank Marian Shields for help with the English.
References [1] Binmoeller KF, Grimm H, Soehendra N. Endoscopic closure of a perforation using metallic clips after snare excision of a gastric leiomyoma. Gastrointest Endosc 1993;39:172–4. [2] Wewalka FW, Clodi PH, Haidinger D. Endoscopic clipping of esophageal perforation after pneumatic dilation for achalasia. Endoscopy 1995;27:608–11. [3] Van Bodegraven AK, Kuipers EJ, Bonenkamp HJ, Meuwissen SGM. Esophago-pleural fistula treated endoscopically with argon beam electrocoagulation and clips. Gastrointest Endosc 1999;50:407–10. [4] Shimamoto C, Hirata I, Umegaki E, Katsu K. Closure of an esophageal perforation due to fish bone ingestion by endoscopic clip application. Gastrointest Endosc 2000;51:736–9. [5] Yoshikane H, Hidano H, Sakakibara A, Kasahara Y, Asada Y, Toya D, et al. Endoscopic repair by clipping of iatrogenic colonic perforation. Gastrointest Endosc 1997;46:464–6.
[6] Kim HS, Lee DK, Jeong YS, Kim KH, Baik SK, Kwon SO, et al. Successful endoscopic management of a perforated gastric dysplastic lesion after endoscopic mucosal resection. Gastrointest Endosc 2000;51:613–5. [7] Negro P, D’Amore L, Saputelli A, Talarico C, Scaccia M, Negro P, et al. Colonic lesions in pancreatitis. Ann Ital Chir 1995;70:223– 31. [8] Warshaw AL, Jin G. Improved survival in 45 patients with pancreatic abscess. Ann Surg 1985;207:408–17. [9] Tsiotos GG, Smith CD, Sarr MG. Incidence and management of pancreatic and enteric fistulas after surgical management of severe necrotizing pancreatitis. Arch Surg 1995;130:48–52. [10] Ho HS, Frey CF. Gastrointestinal and pancreatic complications associated with severe pancreatitis. Arch Surg 1995;130:817–22. [11] Isenmann R, Beger HG. Le sindromi post-chirurgiche dopo interventi sul pancreas. In: Familiari L, Sahel J, editors. Gastroenterologia pratica, vol. IV. Milan: Masson; 2000. p. 275–81. [12] Kaneko T, Akamatsu T, Shimodaira K, Ueno T, Gotoh A, Mukawa K, et al. Non-surgical treatment of duodenal perforation by endoscopic repair using a clipping device. Gastrointest Endosc 1999;50:410–4. [13] Baron TH, Gostout CJ, Herman L. Hemoclip repair of a sphincterotomy-induced duodenal perforation. Gastrointest Endosc 2000;52: 566–8. [14] Cipolletta L, Bianco MA, Rotondano G, Marmo R, Piscopo R. Endoscopic clipping of perforation following pneumatic dilation of esophagojejunal anastomotic strictures. Endoscopy 2000;32:720–2. [15] Rodella L, Laterza E, De Manzoni G, Kind R, Lombardo F, Catalano F, et al. Endoscopic clipping of anastomotic leakages in esophagogastric surgery. Endoscopy 1998;30:453–6.
Brief Clinical Observation
Endoscopic clipping of a colocutaneous fistula following necrotizing pancreatitis: case report P. Familiari a,∗ , A. Macr`ı a , P. Consolo b , L. Angiò a , M.G. Scaffidi b , C. Famulari a , L. Familiari b a b
Emergency Surgery Unit, University of Messina, Messina, Italy Digestive Endoscopy Unit, University of Messina, Messina, Italy Received 11 November 2002; accepted 10 May 2003
Abstract The case described here is of a 73-year-old male patient who developed a colocutaneous fistula following necrotizing pancreatitis, diagnosed by imaging and treated endoscopically by the application of an endoclip. Pancreatic and gastrointestinal fistulas, common complications of surgery for necrotizing pancreatitis, frequently require surgical treatment. Colonic perforations are the most difficult to treat surgically on account of the risk of peritonitis. A technique, namely, endoscopic clips application, has recently been developed to close anastomotic leakages and perforations of the oesophagus, stomach and colon. In the patient described here, endoscopic repair was technically easy and the good result was confirmed within a few days. In order to repair colonic fistulas following pancreatitis, application of endoclips could, in our opinion, provide a useful therapeutic option, feasible in selected patients. © 2003 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved. Keywords: Colonic fistula; Endoclip; Pancreatitis
1. Introduction The endoscopic application of clips is a routine technique for the emergency treatment of gastrointestinal bleeding [1], and has recently been employed in the treatment of anastomotic leakages and, especially, iatrogenic perforations of the oesophagus [2–4], stomach [1] and colon [5]. It is used primarily in the case of perforation due to snare resection of large colonic polyps or to endoscopic mucosectomy [6]. Colocutaneous fistulas require surgical treatment [7], colostomy, surgical resection of the drained colon and later re-anastomosis [8]. We report here a patient who developed a colocutaneous fistula, lately after a surgical phase for necrotizing pancreatitis, that was treated conservatively. 2. Case report A 73-year-old male patient, submitted to surgery for necrotizing pancreatitis, was rehospitalised 60 days later, ∗ Corresponding author. Tel.: +39-090-2212773; fax: +39-090-2921929. E-mail address: [email protected] (P. Familiari).
Fig. 1. Percutaneous fistulography. Fistula is visible between median transverse colon and skin surface. Small arrow: drainage catheter; thick arrow: contrast filling colon.
1590-8658/$30 © 2003 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.dld.2003.05.001
908
P. Familiari et al. / Digestive and Liver Disease 35 (2003) 907–910
complaining of diffuse abdominal pain, fatigue and fever rising to 38 ◦ C in the evening. The surgical procedure consisted of debridement of the infected necrotic areas of the pancreas (head and body), evacuation of peripancreatic fluid collections and multiple drainage tubes associated with cholecystectomy. The patient had been discharged on the 30th post-operative day with two drainage catheters (at the root of the gastrocolic and duodenocolic ligaments and in the left paracolic gutter), which were left in situ on account of the secretion of small amounts of a sieropurulent exudate. At follow-up, in the outpatient unit, the patient was medicated for the drainages. Upon re-admission, physical examination of the abdomen revealed a slight tenderness in the lower quadrants. Routine
blood tests revealed abnormal levels of alkaline phosphatase (1028 IU/l), gamma glutamyl transferase (␥-GT) (263 IU/l), alanine transferase (ALT) (79 IU/l), cholinesterase (1818 IU/l), moderate leukocytosis (10,700/l) and anaemia (red blood cells (RBC) 380,000/l). Leakage of pus and necrotic material from the drainage tubes was observed and at the upper right abdominal quadrant, where another drainage catheter had previously been placed, a fistula 5 mm in diameter secreting enteric-like fluid was present. Percutaneous fistulography was performed, which revealed the presence of a fistula between the median transverse colon and the skin surface; another small fistula was detected in the descending colon which presented
Fig. 2. (a) Endoscopic view of fistula in transverse colon with a guide-wire inserted for easier identification; (b) closure of fistula with clip; (c) endoscopic control 11 days later.
P. Familiari et al. / Digestive and Liver Disease 35 (2003) 907–910
leakage of contrast medium, which was collected by the drainage catheter adjacent to the left colonic wall; the catheter was withdrawn, under fluoroscopic control, for 2 cm (Fig. 1). Abdominal CT scan revealed small collections of fluid on the anterior surface of the pancreas, in the anterior fascia of the kidney, in the pancreatic–splenic ligament and at the hilus of the liver, which, compared to previous examinations, definitely showed signs of regression and, moreover, revealed the presence of a drainage tube inside the transverse colon. Low-pressure Gastrographin® (Schering AG, Berlin, Germany) enema led to retrograde opacification of the drainage catheter localized in the transverse colon, without revealing any leakage from the descending colon. Colonoscopy revealed, in the medium part of the transverse colon, a 6 mm mucosal break, through which the drainage tube had passed. After establishing the diameter of the fistula and the good trophism of the peripheral mucosa, conservative treatment was carried out with the application of an endoscopic clip (Fig. 2a). Then, using a 0.035 in. (0.88 mm) guide-wire, the drainage catheter was withdrawn from the colon and a metal clip (Olympus MD 850, Olympus Europe, Hamburg, Germany) estimated to be suitable to stop the leakage was applied. The guide-wire was removed and drainage of pus and infected fluid from the catheter stopped (Fig. 2b). The patient was submitted to total parenteral nutrition for 7 days. On the 11th day, colonoscopy confirmed complete closure of the fistula and the patient was discharged (Fig. 2c). The two drainage tubes were removed on the 16th day. On the 30th day, control enema confirmed repair of the fistula (Fig. 3). Moreover, CT, performed 5 months later, did not reveal any lesion in the pancreas or surrounding areas and no pathological fluid collections were detected in the abdomen.
Fig. 3. Control enema at 30th day confirmed repair of fistula.
909
3. Discussion Pancreatic and gastrointestinal fistulas are common complications following surgery for infected necrotizing pancreatitis; furthermore, the incidence, in the literature, ranges from 10 to 41% [7–11]. These complications are likely related to parietal necrosis provoked by the combined effect of local ischaemia, due to small-vessel thrombosis and enzymatic digestion [7]; a direct injury caused by the drainage tubes has also been hypothesized. Development of external colonic fistulas often follows the surgical drainage of the pancreas. Colonic fistulas often need surgical repair, such as simple suture closure, protective colostomy, or even resection with anastomosis, which implicates a high morbidity and mortality risk for the patient [8–10]. First described exclusively for emergency haemostasis of gastrointestinal bleeding, the endoscopic application of clips was performed, in 1993, by Binmoeller et al. for the treatment of iatrogenic gastric perforation [1]. Since then, several cases of iatrogenic perforations of the oesophagus, stomach and colon, following polypectomy, mucosectomy, biliary stent dislocation, endoscopic pneumatic dilation or accidental perforations due to removal of foreign bodies, have been successfully treated with the use of the endoscopic clip [2–5,12–14], such as closure of anastomotic leaks following oesophago-gastric surgery [15]. In the case reported here, endoscopic repair, by clip application, was necessary due to a colocutaneous fistula which developed after necrosectomy and introduction of drainage tubes in a patient with infected necrotizing pancreatitis. The endoscopic repair of the leak was technically easy; the fistula was rapidly identified and one clip was sufficient to achieve a good result with healing of the orifice in a few days. During follow-up, 5 months later, diagnostic examinations confirmed the successful outcome both of the pancreatic inflammation and the colonic fistula. The success of the endoscopic clip in the management of a fistula has been generally recognized, the success depending on several factors, such as its size, the time elapsing between development of the fistula and treatment and patient’s otherwise good state of health; diffused peritonitis or necrosis at the borders of the leakage and peripheral tissues advise against conservative treatment of the fistula [12]. Since in our patient the fistula was small in size, the colonic mucosa around it was in a good condition and clinical presentation was late, these data led us to consider the development of the lesion as iatrogenic, due to perforation caused by the drainage catheter. In conclusion, even though no generalized treatment can be defined, at present, the application of endoclips in the repair of colonic fistulas following pancreatitis could provide a new worthwhile therapeutic option, feasible in properly selected patients.
910
P. Familiari et al. / Digestive and Liver Disease 35 (2003) 907–910
Conflict of interest statement None declared. Acknowledgements Authors thank Marian Shields for help with the English.
References [1] Binmoeller KF, Grimm H, Soehendra N. Endoscopic closure of a perforation using metallic clips after snare excision of a gastric leiomyoma. Gastrointest Endosc 1993;39:172–4. [2] Wewalka FW, Clodi PH, Haidinger D. Endoscopic clipping of esophageal perforation after pneumatic dilation for achalasia. Endoscopy 1995;27:608–11. [3] Van Bodegraven AK, Kuipers EJ, Bonenkamp HJ, Meuwissen SGM. Esophago-pleural fistula treated endoscopically with argon beam electrocoagulation and clips. Gastrointest Endosc 1999;50:407–10. [4] Shimamoto C, Hirata I, Umegaki E, Katsu K. Closure of an esophageal perforation due to fish bone ingestion by endoscopic clip application. Gastrointest Endosc 2000;51:736–9. [5] Yoshikane H, Hidano H, Sakakibara A, Kasahara Y, Asada Y, Toya D, et al. Endoscopic repair by clipping of iatrogenic colonic perforation. Gastrointest Endosc 1997;46:464–6.
[6] Kim HS, Lee DK, Jeong YS, Kim KH, Baik SK, Kwon SO, et al. Successful endoscopic management of a perforated gastric dysplastic lesion after endoscopic mucosal resection. Gastrointest Endosc 2000;51:613–5. [7] Negro P, D’Amore L, Saputelli A, Talarico C, Scaccia M, Negro P, et al. Colonic lesions in pancreatitis. Ann Ital Chir 1995;70:223– 31. [8] Warshaw AL, Jin G. Improved survival in 45 patients with pancreatic abscess. Ann Surg 1985;207:408–17. [9] Tsiotos GG, Smith CD, Sarr MG. Incidence and management of pancreatic and enteric fistulas after surgical management of severe necrotizing pancreatitis. Arch Surg 1995;130:48–52. [10] Ho HS, Frey CF. Gastrointestinal and pancreatic complications associated with severe pancreatitis. Arch Surg 1995;130:817–22. [11] Isenmann R, Beger HG. Le sindromi post-chirurgiche dopo interventi sul pancreas. In: Familiari L, Sahel J, editors. Gastroenterologia pratica, vol. IV. Milan: Masson; 2000. p. 275–81. [12] Kaneko T, Akamatsu T, Shimodaira K, Ueno T, Gotoh A, Mukawa K, et al. Non-surgical treatment of duodenal perforation by endoscopic repair using a clipping device. Gastrointest Endosc 1999;50:410–4. [13] Baron TH, Gostout CJ, Herman L. Hemoclip repair of a sphincterotomy-induced duodenal perforation. Gastrointest Endosc 2000;52: 566–8. [14] Cipolletta L, Bianco MA, Rotondano G, Marmo R, Piscopo R. Endoscopic clipping of perforation following pneumatic dilation of esophagojejunal anastomotic strictures. Endoscopy 2000;32:720–2. [15] Rodella L, Laterza E, De Manzoni G, Kind R, Lombardo F, Catalano F, et al. Endoscopic clipping of anastomotic leakages in esophagogastric surgery. Endoscopy 1998;30:453–6.