A novel combination of endoscopic therapies has demonstrated remarkable success in the treatment of a duodenal fistula, a rare but life-threatening complication that can occur after trauma or abdominal surgery. These fistulas are challenging to manage because they continuously leak intestinal contents, putting patients at risk of severe infection and malnutrition. Conventional surgery carries significant risks and often fails to achieve durable closure, making minimally invasive alternatives urgently needed. This innovative case highlights the potential of advanced endoscopic approaches for conditions that traditionally required high-risk surgical intervention.
The case, conducted by Dr. Gustavo de Carvalho Bertaccini Guriam and his team at São Francisco Hospital – Hapvida, and published in VideoGIE, involved a young man who sustained a duodenal perforation following a motorcycle accident. Despite multiple surgical attempts to repair the injury, the patient developed a persistent duodenal fistula, resulting in continuous leakage of intestinal contents and recurrent intra-abdominal infection. Imaging revealed a large retroperitoneal collection, and upon referral, the team opted for a combined endoscopic approach rather than additional surgery.
The treatment consisted of three complementary techniques:
- A modified endoscopic vacuum therapy (EVT) system, providing continuous suction to remove infected fluid and promote granulation;
- Endoscopic internal drainage (EID) using double-pigtail stents to ensure effective evacuation and internal decompression; and
- An over-the-scope clip (OTSC), used in the final stage to achieve complete closure of the fistula.
Dr. Guriam explained, “The association of internal drainage with endoscopic vacuum therapy was crucial for the case. In addition to draining the purulent secretion from the cavity into the duodenal lumen, it promoted local debridement and allowed direct transmission of negative pressure, enhancing the healing process.”
The treatment was performed in sequential sessions over several weeks, with progressive reduction of the cavity and improvement in the patient’s clinical condition. After approximately three months, an OTSC was placed to seal the residual fistula, achieving definitive closure and enabling safe discharge. Follow-up confirmed complete healing, with spontaneous passage of the clip and no evidence of recurrence.
This case underscores the expanding role of advanced endoscopic therapy in managing complex gastrointestinal transmural defects. As Dr. Guriam emphasized, “Endoscopic management for GI tract wall defects is increasingly becoming the first-line approach due to its high success rate, minimally invasive nature, and lower morbidity.”
The successful integration of multiple endoscopic modalities in this case demonstrates the feasibility and safety of a multimodal endoscopic strategy, offering a valuable alternative to surgery for high-risk patients with challenging GI leaks and fistulas.
Journal Reference
Guriam G.C.B., Furtado T.C.M., Chini R., Pacheco E.G., Delmonaco L.O., Pinton G.M., Mendes J.A.M., Santos V.C. “Treatment of duodenal fistula with combined endoscopic therapy: modified endoscopic vacuum, endoscopic internal drainage, and the over-the-scope clip.” VideoGIE. 2025; 10(6). DOI: https://doi.org/10.1016/j.vgie.2025.01.011
