Transcolonic necrosectomy with endoscopic closure, turning adversity into opportunity. Iatrogenic gastrointestinal fistula, secondary to percutaneous catheter drainage in the management of pancreatic necrotic collection, is not uncommon. The most common site of such fistula are usually the colon and the duodenum. Colonic fistulae with deteriorating clinical scenario often requires surgical intervention. We discuss here a case of a 68-year-old obese female with multiple comorbidities who developed gallstone-related acute necrotizing pancreatitis. For infected pancreatic necrosis, percutaneous catheter drainage was placed. After the initial improvement, there was deterioration of symptoms with worsening sepsis. The PCD catheter showed feculent material two days later, raising a suspicion of a colonic fistula. She was a poor surgical candidate and not willing for surgical necrosector. Colonoscopy revealed an iatrogenic fistula caused by the PCD catheter with a large rent at the distal part of the transverse colon. She underwent transcolonic necrosectomy under CO2 insufflation and the colonic rent was subsequently closed using clip-loop technique. On colonoscopy, large amount of necrotic material was seen extruding inside the lumen of the colon. The distal part of the percutaneous catheter was noted projecting from the cavity through the rent in the colonic wall into the lumen. The large rent in the colonic wall with protruding catheter tip and necrotic material was noted. Transcolonic necrosectomy with snare was performed. In this fashion, three sessions of necrosectomy was performed. Post necrosectomy, the clean cavity is noted. Clip and loop technique was then employed to close the rent in the colonic wall. The first clip is applied. Subsequent clips were applied encircling the rent margin with the loop. Once the clipping was completed, the loop was tightened using the applicator. The rent in the colonic wall was thus closed. Clips are seen on X-ray. CCT done two days later showed clips in situ with no leak. Post-procedure, PCD output gradually decreased over a period of the next four days. Repeat imaging showed no residual collection, patient improved, and patient was discharged eight days post-procedure after the removal of PCD. On nine months follow-up, patient is doing well with no recurrence of collection. Surgical necrosectomy could be avoided in this case using this endoscopic technique. Selective cases of colonic fistula which develops in cases of acute pancreatitis can be managed endoscopically avoiding surgery. Transcolonial necrosectomy can be safely conducted after which the large dent can be effectively using clip-loop technique.

colonic fistula

endoscopic closure

necrosectomy

obese female

gallstone-related