Pyloric Exclusion with Ovesco (Over-the-scope-clip) Device for Jejunal Fistula in Duodenal Obstruction of Malignant Etiology

Abstract

A 25-year-old man diagnosed with a non-seminomatous germ cell tumor was admitted to the emergency department for diffuse abdominal pain associated with bloating and multiple emetic episodes. Due to the clinical suspicion of intestinal obstruction, a contrasted abdominal tomography was performed, showing an obstruction in the third duodenal portion resulting from extrinsic compression caused by multiple retroperitoneal conglomerates.

Surgical time was scheduled for a gastric bypass surgery where gastrojejunostomy was performed using conventional technique. On the fifth postoperative day, he presented clinical deterioration due to febrile episodes, abdominal pain, and tachycardia. A new abdominal tomography was performed, reporting an intra-abdominal collection of pus on the left flank of 12 x 12 x 5 cm secondary to the jejunal fistula process. Hence, percutaneous drainage management of the collection was performed by interventional radiology and drainage catheter placement. In addition, an EGD was performed to conduct a pyloric exclusion technique with an Ovesco (over-the-scope-clip) device for managing the jejunal fistula, which was technically successful.

A gastrointestinal tract X-ray was performed as a follow-up during the postoperative stage, showing no pyloric continuity with adequate patency of the gastrojejunostomy. In addition, a contrasted abdominal CT scan showed a decrease in the intra-abdominal collection without extravasation of the contrast medium.

This case outcome suggests the Ovesco device may be helpful in proximal GI fistulas cases, especially in patients with multiple comorbidities or poor general conditions who may benefit from minimally invasive procedures decreasing the risk of fatal outcomes.