West Virginia University Health Sciences Center Morgantown, WV, United States
Momin Shah-Khan, MD1, Yousaf Hadi, MD2, Shyam Thakkar, MD1, Shailendra Singh, MD2 1West Virginia University Health Sciences Center, Morgantown, WV; 2West Virginia University, Morgantown, WV
Introduction: Walled off pancreatic necrosis (WOPN) is a devastating complication of acute pancreatitis. These collections can be further complicated by spontaneous fistula formation with adjacent organs due to chronic pressure. Management of fistulous connections often include surgery but may be managed endoscopically when luminal organs are involved. We present a case of acute pancreatitis complicated by WOPN further complicated by the development of a pancreaticocolonic fistula.
Case Description/Methods: A 35 year old female recently discharged from our facility two months prior for acute biliary pancreatitis complicated by WOPN presented with abdominal pain. In her prior admission, CT imaging revealed a peripancreatic fluid collection extending from the mid-abdomen along the paracolic gutters to the pelvis. The patient underwent EUS-guided cystgastrostomy with a lumen apposing metal stent (LAMS) and serial direct endoscopic necrosectomy with clinical improvement and subsequent LAMS removal. She was discharged with plans for repeat imaging but was lost to follow up. Repeat CT on her return showed near resolution of her perigastric collection but revealed it to no longer communicate with the left lower quadrant (LLQ) collection which now measured 6.8 x 10.2 cm. The patient underwent CT guided drain placement into the collection and contrast injection through the drain showed extravasation into the descending colon revealing a fistula. A multidisciplinary meeting was held and plans for endoscopic fistula closure were made. The patient underwent a colonoscopy which revealed a fistula defect in the descending colon. Argon plasma coagulation was performed on the fistulous tract to promote deepithelialization and tissue apposition. Endoscopic suturing was performed on the defect using a helix tack device (X-Tack, Apollo Endosurgery, Austin, TX, USA). A total of 8 tacks were placed across the defect which was closed successfully. The patient’s drain output gradually improved, and she underwent repeat CT one month later which revealed a near resolution in her LLQ collection. She then underwent a barium enema which revealed no evidence of contrast extravasation into her colon and her drain was removed.
Discussion: Pancreaticocolonic fistulas are a rare but known complication of WOPN extending into the pelvis. While there are reports of endoscopic fistula closure using over the scope clips, our case shows the efficacy of endoscopic suturing using a novel helix tack device.
Momin Shah-Khan indicated no relevant financial relationships.
Yousaf Hadi indicated no relevant financial relationships.
Shyam Thakkar indicated no relevant financial relationships.
Shailendra Singh indicated no relevant financial relationships.
Momin Shah-Khan, MD1, Yousaf Hadi, MD2, Shyam Thakkar, MD1, Shailendra Singh, MD2. P0677 - Endoscopic Suturing of a Pancreaticocolonic Fistula Using a Novel Helix Tack Device, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.