Published in:
22-09-2022 | Crohn's Disease | Image of the Month
Modified Percutaneous Endoscopic Gastrojejunostomy for Duodenal Fistula
Published in: Digestive Diseases and Sciences | Issue 12/2022
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Duodenal fistula rarely occurs in patients with Crohn’s disease (CD), most arising from recurrent disease at the ileocolic anastomosis [1]. The treatment for duodenal fistula includes medical or surgical management, and surgery is often required [1‐3]. We report the case of a 32-year-old male diagnosed with CD 8 years prior. He had undergone four operations owing to external and internal fistulas. However, the duodenal fistula recurred after operations, and was also unsuccessfully treated with medical therapy and a patch blocking (Fig. 1). Reoperation was not feasible in the short term, so the conservative treatment is challenging. We made a modified percutaneous endoscopic gastrojejunostomy (PEG-J) that was placed though the abdominal fistula to achieve decompression and enteral nutrition (Figs. 2, 3). The patient had no complications of duodenal fistula. One year later, the duodenal fistula was successfully treated by surgery (Fig. 4). We suggest that modified PEG-J is an option to treat upper gastrointestinal fistula that is inoperable.
Fig. 1
Treatment of duodenal fistula. A The abdominal incision healed after skin grafting, but there were three enterocutaneous fistulas including the duodenal fistula recurrence. B Duodenal fistula (diameter 12 mm) at the descending part of the duodenum was confirmed by endoscopy. C The fourth operation was duodenal repair, terminal ileum and ileocolon anastomosis resection, ileostomy, and full-thickness abdominal wall tensioning suture. Three fistulas were observed in surgical removed bowel. D The fistula (diameter 8 mm) was smaller after the fourth operation than before. E A patch (diameter 2 cm) was made to block the duodenal fistula. F A nasointestinal tube was placed for enteral nutrition. G Duodenal fistula did not heal after placement of patch
Fig. 2
Modified percutaneous endoscopic gastrojejunostomy. A Illustration showing modified percutaneous endoscopic gastrojejunostomy to block duodenal fistula. B A larger circular patch (diameter 4.5 cm) was made behind the internal bumper of PEG. C Modified percutaneous endoscopic gastrostomy
Fig. 3
Endoscopic procedure of modified percutaneous endoscopic gastrojejunostomy. A A thin wire through the needle was inserted into the fistula. B The thin wire was pulled by endoscope. C A gastrostomy tube was placed, and the circular patch behind the internal bumper was used to block the fistula. D A jejunostomy tube was placed into the proximal jejunum. E The abdominal incision was healed. F Abdominal wall fistula has no exudation or inflammation
Fig. 4
Surgical treatment after readmission. A Duodenal fistula was observed during the operation. B Duodenal fistula healed after reoperation
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