Palliation of a malignant gastrocolic fistula with the use of an atrial septal defect occlusion device

Abstract

A 51-year-old Asian man with metastatic gastric adenocarcinoma presented with a 3-month history of profound diarrhea and weight loss. Laboratory evaluation was significant for anemia and hypokalemia. Computed tomography showed large tumor burden from the gastric antrum with invasion into the ascending colon. Esophagogastroduodenoscopy (EGD) revealed a gastrocolic fistula 30 mm in diameter within the posterior wall of the gastric antrum, extending for 6 cm and opening into the ascending colon (• " Fig. 1) along with partial obstruction of the pyloric channel. Following discussion of therapeutic options, the patient consented to off-label use of an atrial septal defect (ASD) occlusion device to treat the fistula. Endoscopically, a guidewire was advanced through the fistula tract into the transverse colon. After fluoroscopic sizing with a 34-mm sizing balloon, a 36-mm ASD occlusion device (Amplatzer, St. Jude Medical, St. Paul, Minnesota, USA) was deployed into the tract over the wire alongside the scope. The distal (left atrial) disc was seated within the tract with the proximal (right atrial) disc within the gastric lumen. Injection of contrast revealed little passage of contrast into the fistula. A duodenal stent was then deployed across the pylorus (• " Fig. 2). At 6 weeks later the patient had no further diarrhea and his weight had stabilized. Abdominal films showed both devices in stable position.Gastrocolic fistulas have been reported as a very rare complication of malignant tumors. In a review of 1500 cases of cancer of the stomach and 3200 cases of carcinoma in the colon, only 11 cases of gastrocolic fistula were found, of which only one case was caused by gastric carcinoma [1]. This case illustrates the novel (but offlabel) use of an ASD closure device combined with a duodenal stent for palliation of a large inoperable malignant gastrocolic fistula and gastric outlet obstruction. Endoscopy_UCTN_Code_TTT_1AO_2AICompeting interests: None

Benign Peptic Ulcer as a Cause of Gastrocolic Fistula

“…9 A few reported cases in the literature show successful treatment of a gastrocolic fistula using a cardiac septal defect closure device, direct clipping, colonic stent placement, or wire-guided simultaneous dual scope approach. [10][11][12][13] Our patient was successfully treated surgically and had an uneventful postoperative course after undergoing a robotassisted laparoscopic partial omentectomy, Billroth II gastrojejunostomy, Braun enteroenterostomy, and segmental transverse colectomy with side-to-side isoperistaltic anastomosis.…”

Role of Cardiac Septal Occluders in the Treatment of Gastrointestinal Fistulas: A Systematic Review

“…Perretta et al 40 demonstrated the efficacy of CSOs in the closure of gastrostomy defects in porcine models, showing a 100% success closure rate, without any adverse events. Malespin et al 41 used an ASD device to close a malignant gastrocolonic fistula with adjunctive therapy and duodenal stenting and reported successful closure after 6 weeks, suggesting that success was achieved because of the ASD device. The other seven studies were excluded because they did not use ASD or VSD AMPLATZER TM occluder devices.…”

Gastrocolic Fistula: A Rare Presentation of Colon Cancer

“…A few novel methods have been described that do not involve surgery; to mention a few, in the case of Nici et al, dual endoscopic closure was achieved with use of Resolution clips [ 15 ]. Also in a case of large inoperable malignant gastrocolic fistula and gastric outlet obstruction, Malespin et al combined an Atrial Septal Defect closure device and a duodenal stent for palliation [ 16 ]. Though our patient's age was in the mid-80s, she was a good fit for surgical intervention and CT scan revealed clear boundaries for resection.…”