Successful percutaneous transgastric diversion of a chronic post-operative combined pancreaticocutaneous and gastrocutaneous fistula using a snare-target technique: A case report

INTRODUCTION: Gastrocutaneous fistula complicating a post-operative or post-pancreatitis pancreatic fistula is uncommon, but has a high mortality rate and typically occurs 6–9 weeks after initial drainage. Conventional methods of treatment may be limited by the size of the fistula tract and visibility. PRESENTATION OF CASE: A 57-year-old man presented with a pancreatic duct leak, ten days after undergoing a distal pancreatectomy for renal cell carcinoma metastasis. Initial drainage attempts resulted in a chronic pancreaticocutaneous fistula (PCF) complicated by a separate gastric fistula sharing the same cutaneous tract along the inserted drain as well as recurrent symptomatic pleural effusions requiring repeat hospitalizations for management. The chronic fistula tract was too small for conventional direct puncture under fluoroscopic or endoscopic ultrasound guidance; therefore, percutaneous transgastric diversion of the combined pancreatico-gastrocutaneous fistula using a snare-target approach was performed with complete resolution of clinical symptoms. DISCUSSION: Complicated pancreatico-gastrocutaneous fistulae are rare and typically require drainage, either surgically or via percutaneous direct transgastric puncture or endoscopic-ultrasound guided stent insertion. This case report demonstrates that a minimally-invasive percutaneous snare-target approach can be effective in treating complex fistulae too small to be accessed through these conventional methods. This case also demonstrates that transgastric drainage along the tract, remote from either organ’s fistula origin, can successfully divert and resolve the complex fistula without requiring direct drainage of the pancreatic duct itself. CONCLUSION: Incorporating the snare-target technique facilitates accurate transgastric drain placement within chronic fistula, particularly when the fistula caliber is too small for conventional drainage methods.