An unusual case of high gastrointestinal bleeding after Whipple surgery.

Pancreatic cancer is an aggressive malignancy with poor survival rates. Pancreatic surgery has improved outcomes in the last few decades, but still contains high morbidity rates. Pancreatic fistula, delayed gastric emptying, intra-abdominal infections and bleeding are well-known complications. We report a case of a 57-year old woman with a portogastric fistula complicated with high gastrointestinal bleeding and septic thrombophlebitis after pancreaticoduodenectomy for pancreatic adenocarcinoma.

Endoscopic purse-string suture and naso-jejunal tube feeding for duodenal cutaneous fistula and gastric cutaneous fistula.

BACKGROUND: The Endoscopic Purse-string Suture (EPSS) technique has gained attention for its potential in closing large defects following gastrointestinal procedures. However, its application in fistula closure is not as widely reported. This study aims to evaluate the safety and efficacy of EPSS and naso-jejunal tube feeding in the closure of duodenal cutaneous fistulas and gastric cutaneous fistulas. METHODS: This single-center retrospective study, conducted from September 2020 to September 2023 at Tongji University in Shanghai, China, examined the outcomes of EPPS and nasojejunal feeding for patients with gastric and duodenal cutaneous fistulas (n = 10). Demographic data, fistula characteristics, procedure technique and outcomes were evaluated. RESULTS: In this study, the average size of a fistula opening was 7.9 ± 4.6 mm. The operations took an average of 25.8 ± 5.6 min. Patients typically needed naso-jejunal tube feeding for a median of 14.0 days, with an interquartile range (IQR) of 7.7-19.0 days. The median duration of hospital stay post-operation was 16.5 days, with an IQR of 7.0-25.0 days. Nine patients were successful in their initial fistula closure using the EPSS technique. The other patient underwent a second EPSS and, ultimately, all patients experienced complete healing and fully recovered. There were no major adverse events reported. CONCLUSIONS: EPSS and naso-jejunal tube feeding are a safe and effective treatment option for duodenal and gastric cutaneous fistulas. Larger, prospective studies are needed to validate these findings and establish the long-term safety and efficacy of this approach.

Endoscopic Management of Bariatric Surgery Complications: Fistulas, Leaks, and Ulcers.

Bariatric surgery is a safe and effective treatment option for patients with obesity and obesity-related comorbidities, with Roux-en-Y gastric bypass and sleeve gastrectomy being the two most common procedures. Despite the success of these interventions, adverse events are not uncommon. Endoscopic management has become first-line therapy when complications occur, and the armamentarium of devices and techniques continues to grow. This article focuses on the management of fistulas, leaks, and ulcers and also focuses on the etiology and endoscopic management strategy of each complication.

How to clip a gastrocutaneous fistula.

We present a simple, yet effective, approach for surgically managing chronic gastrocutaneous fistulas. This procedure can be easily performed under local anaesthesia if needed. Our derived experience is largely based on gastrocutaneous fistulas, but we have also used this approach on small bowel fistulas.

Spontaneous Twin Internal Fistulae: A Rare Complication of Acute Pancreatitis.

Spontaneous internal fistulae (cystocolonic, cystogastric and cystoenteric) have been described as potential complications of severe acute pancreatitis with pseudocyst or walled off necrosis (WON). Ours is possibly the first ever report of double internal fistulae (pancreatico-gastric and pancreatico-colonic) occurring as a spontaneous complication of acute pancreatitis.

Over-the-scope clip for closure of persistent gastrocutaneous fistula after gastrostomy tube removal: a multicenter pediatric experience.

BACKGROUND: Percutaneous endoscopic gastrostomy is commonly used for enteral nutritional access, but gastrocutaneous fistulae (GCF) may persist after tube removal, posing clinical challenges. The use of endoscopic closure devices, including over-the-scope clips (OTSC), has shown promise in managing non-healing fistulae, although data in the pediatric population are limited. METHODS: A retrospective multicenter study analyzed pediatric patients who underwent GCF closure following gastrostomy tube removal. Data from seven centers across multiple countries were collected, including patient demographics, procedural details, complications, and outcomes. Closure techniques were compared between OTSC and surgical closure. RESULTS: Of 67 pediatric patients included, 21 underwent OTSC closure and 46 had surgical closure. Surgical closure demonstrated a higher success rate (100%) compared to OTSC closure (61.9%, P < 0.001). While procedural duration was shorter for OTSC closure (25 vs. 40 min, P = 0.002), complications, and scar quality were comparable between techniques. A subsequent sub-analysis did not reveal differences based on center experience. CONCLUSION: OTSC closure is feasible and safe in pediatric patients, but surgical closure remains superior in achieving sustained GCF closure, although OTSC offers benefits, such as shorter procedural duration, potentially reducing the duration of general anesthesia exposure. Non-operative approaches, including OTSC, may be a valuable alternative to surgical closure.

Ruptured giant splenic artery aneurysm with an exceptional concurrent gastric and transverse colonic fistula: A rare case report.

INTRODUCTION: Splenic artery aneurysm (SAA) is a focal dilation of the splenic artery with varying etiologies including atherosclerosis, arteritis, or trauma. Giant SAAs with a diameter of 10 cm is rare and can lead to severe complications like rupture and fistulas. Therefore, an accurate and timely diagnosis and treatment are important. PATIENT CONCERNS: A 50-year-old male presented with acute epigastric pain and hemorrhagic shock. Considering his symptoms and examination, ultrasound, multi-slice computed tomography and digital subtraction angiography results, a ruptured giant splenic artery aneurysm complicated with an exceptional gastric and transverse colonic fistula was suspected. DIAGNOSIS: Ruptured giant splenic artery aneurysm. INTERVENTIONS: Left anterolateral thoracotomy to control the severe aortic bleeding just above the diaphragm, aneurysmectomy, splenectomy, and closing the gastric and transverse colon perforations. OUTCOMES: Multi-slice computed tomography demonstrated the presence of splenic artery aneurysm in the distal third measuring (10 × 12 cm) in diameter with a true lumen measuring (7 × 3.5 cm) and a large hematoma extending to the greater and lesser gastric curvature. Intraoperatively, a large pulsating mass was detected occupying the epigastrium and the left hypochondrium with severe adhesions with the stomach and transverse colon. CONCLUSION: Giant SAA with a diameter of 10 cm is rare and is associated with severe complications. Therefore, successful treatment of splenic artery aneurysms involves prompt diagnosis, immediate surgical intervention to control bleeding, and tailored approaches like thoracotomy to control the thoracic aorta for better hemodynamic stabilization, aiming to eliminate the aneurysm and reduce complications effectively.

Management of fistulas in the upper gastrointestinal tract.

Fistulas in the upper gastrointestinal (GI) tract are complex conditions associated with elevated morbidity and mortality. They may arise as a result of inflammatory or malignant processes or following medical procedures, including endoscopic and surgical interventions. The management of upper GI is often challenging and requires a multidisciplinary approach. Accurate diagnosis, including endoscopic and radiological evaluations, is crucial to build a proper and personalized therapeutic plan, that should take into account patient's clinical conditions, time of onset, size, and anatomical characteristics of the defect. In recent years, several endoscopic techniques have been introduced for the minimally invasive management of upper GI fistulas, including through-the-scope and over-the-scope clips, stents, endoscopic suturing, endoluminal vacuum therapy (EVT), tissue adhesives, endoscopic internal drainage. This review aims to discuss and detail the current available endoscopic techniques for the treatment of upper GI fistulas.

Laparoscopic Management of Gastrocolic Fistula in a Patient with a History of an Unusual Loop Gastric Bypass-a Video Vignette.

Gastrocolic fistula (GCF) is defined as an abnormal pathological communication between the epithelialized mucosal layers of the stomach and colon. In rare cases, complications following gastric bypass surgery, such as leakage or complicated marginal ulcers, may contribute to the development of a GCF. The laparoscopic approach for managing GCF involves a one-stage procedure that includes resection of the fistula and reconstruction of the gastrointestinal tract.

Gastrosplenic Fistula and/or Splenic Abscess: A Rare and Refractory Complication Following Sleeve Gastrectomy.

Splenic abscess is a rare complication often associated with sleeve gastrectomy (SG) due to factors including local infections, distant infections, tumors, ischemia, and trauma, which presents substantial challenges. We report four cases of gastrosplenic fistula and/or splenic abscess after SG. Patient data, including demographics, comorbidities, diagnostic procedures, treatments, and outcomes, were recorded. Surgical techniques for SG adhered to established protocols. Four patients had a male-to-female ratio of 2:2, with an average age of 39.8 years and an average preoperative BMI of 38.9 kg/m2. All patients were readmitted due to recurrent fever and chills caused by splenic abscesses detected on CT scans, with an average admission duration of 16.5 weeks. Treatments varied from fasting and antibiotics to percutaneous drainage and surgical interventions. The average treatment duration post-diagnosis of splenic abscess was 37.25 weeks. Managing gastrosplenic fistula and/or splenic abscess is complex, underscoring the significance of prompt diagnosis and proper treatment. This highlights the need for heightened awareness among healthcare professionals to promptly recognize and manage this rare complication after SG.

Gastropericardial fistula: A successfully operated heart code.

Gastropericardial fistula is a rare, extremely serious and life-threatening condition. Its most common aetiology is secondary to iatrogenic injury following gastric surgery. Clinical manifestations may be non-specific with precordial pain, simulating an acute coronary syndrome, and may be accompanied by electrocardiogram abnormalities. Diagnosis is made by thoracoabdominal computed tomography (CT) with oral and intravenous contrast. Treatment is surgical and consists of repair of the anomalous communication. We present the case of an 81-year-old male patient with gastropericardial fistula who underwent surgery, with the aim of reviewing the diagnosis and the appropriate therapeutic strategy.

Effectiveness and safety of a ventricular septal occluder device for the treatment of Gastro-tracheal fistula.

BACKGROUND: Gastro-tracheal fistula (GTF) is one of the most serious complications after esophagogastrostomy and radiotherapy, with very high disability and mortality rates. To evaluate the effectiveness and safety of ventricular septal occluder devices (VSOD) for the treatment of Gastro-tracheal fistula (GTF). METHODS: From January 2020 to May 2022, 14 patients with GTF underwent VSOD under real-time fluoroscopy. The technical success, complications, quality of life (QoL), Eastern Cooperative Oncology Group (ECOG) score, Karnofsky score, and median overall survival (mOS) were recorded and analyzed. RESULTS: Technical success, and major complication rates were 71.4%, and 14.3%, respectively. Both the ECOG and the Karnofsky score showed significant improvement at the 2-month evaluation compared with the pretreatment value (p<0.05). For QoL, general health, physical function, vitality, role physical, and social function all improved at the 2-month evaluation (p<0.05), but bodily pain, role emotion, and mental health showed no significant difference (P>0.05). During the mean follow-up of 9.6 months, eight patients were alive, and the mOS was 11.4 months (95% CI, 8.5-14.3). CONCLUSIONS: VSOD is a simple and safe technique for GTF treatment, but long-term observation is needed at multiple centers to confirm our findings.

Endoscopic closure techniques of bariatric surgery complications: a meta-analysis.

BACKGROUND: Leaks following bariatric surgery, while rare, are potentially fatal due to risk of peritonitis and sepsis. Anastomotic leaks and gastro-gastric fistulae following Roux-En-Y gastric bypass (RYGB) as well as staple line leaks after sleeve gastrectomy have historically been treated multimodally with surgical drainage, aggressive antibiotic therapy, and more recently, endoscopically. Endoscopic clipping using over-the-scope clips and endoscopic suturing are two of the most common approaches used to achieve full thickness closure. METHODS: A systematic literature search was performed in PubMed to identify articles on the use of endoscopic clipping or suturing for the treatment of leaks and fistulae following bariatric surgery. Studies focusing on stents, and those that incorporated multiple closure techniques simultaneously, were excluded. Literature review and meta-analysis were performed with the PRISMA guidelines. RESULTS: Five studies with 61 patients that underwent over-the-scope clip (OTSC) closure were included. The pooled proportion of successful closure across the studies was 81.1% (95% CI 67.3 to 91.7). The successful closure rates were homogeneous (I2 = 39%, p = 0.15). Three studies with 92 patients that underwent endoscopic suturing were included. The weighted pooled proportion of successful closure across the studies was shown to be 22.4% (95% CI 14.6 to 31.3). The successful closure rates were homogeneous (I2 = 0%, p = 0.44). Three of the studies, totaling 34 patients, examining OTSC deployment reported data for reintervention rate. The weighted pooled proportion of reintervention across the studies was 35.0% (95% CI 11.7 to 64.7). We noticed statistically significant heterogeneity (I2 = 68%, p = 0.04). One study, with 20 patients examining endoscopic suturing, reported rate of repeat intervention 60%. CONCLUSION: Observational reports show that patients managed with OTSC were more likely to experience healing of their defect than those managed with endoscopic suturing. Larger controlled studies comparing different closure devices for bariatric leaks should be carried out to better understand the ideal endoscopic approach to these complications.