Oesophageal stent placement to treat a massive iatrogenic duodenal defect after laparoscopic cholecystectomy

Abstract

Iatrogenic duodenal injury occurring during laparoscopic cholecystectomy (LC) is managed surgically, though rarely a large, persistent fistula is refractory to surgical interventions. We present the case of a 40-year-old woman transferred to our centre following elective LC for a reported perforated duodenal ulcer. An uncontained leak was found to originate from a 1.5 cm duodenal defect, with no evidence of ulceration. A duodenostomy tube was placed. One month after abdominal closure, the patient continued to have a persistent, large duodenal fistula. A through-the-scope covered oesophageal stent was placed under endoscopic and fluoroscopic guidance. Five weeks later, it was successfully retrieved and no subsequent extravasation of contrast from the duodenum was noted. Unrecognised iatrogenic duodenal injuries sustained during LC can be catastrophic. In cases of massive duodenal defects and high-output biliary fistula uncontrolled after surgical intervention, endoscopic-guided and fluoroscopic-guided placement of a fully covered oesophageal stent may be lifesaving.

Keywords: Biliary intervention; Endoscopy; GI stents; Gastrointestinal surgery; General surgery.

Figure 1

Through-the-scope self-expanding metal oesophageal stent placed over duodenal fistula in first portion of duodenum with anchoring clips to prevent distal migration.

Figure 2

Abdominal anteroposterior X-ray demonstrating the oesophageal stent covering a massive duodenal defect. Also shown is a transduodenal jejunal feeding tube and an internal/external biliary stent to allow for improved enteral nutrition and biliary drainage, placed by an interventional radiologist.