Two-step two-stent technique to manage a large gastrocolonic fistula.

Gastrocolonic malignant fistulas can occur, although rarely, complicating gastric or colonic neoplasms. En bloc resection of the fistulous tract and involved segments is the first-line treatment whenever possible, with endoscopic treatment an alternative. Endoscopic closure has been described using covered stents [1, 2], over-the-scope clips [3], and atrial septal defect occlusion devices [4]. However, in the colon, covered stents are associated with a high migration risk [5]. We therefore developed a new technique to allow fistula closure, overcoming the risks of stent migration by initially placing an uncovered stent, which is followed by the deployment of a covered stent inside the first stent a few days later and fixation of the two stents to each other using through-the-scope clips. Our patient, a 58-year-old woman, had a metastatic and locally advanced intestinal-type gastric cancer with colonic invasion. After receiving 12 cycles of palliative chemotherapy, she was admitted with fecaloid emesis and a computed tomography (CT) scan showed a large fistulous tract (approximately 5 cm in length with a large orifice) between the stomach and the transverse colon. Although the patient had a good performance status, surgical resection was not considered feasible and endoscopic palliation was proposed. Esophagogastroduodenoscopy (EGD) showed a large ulcerated neoplasm in the greater curvature of the gastric antrum, with a large orifice communicating with an ulcerated fistulous tract. Colonoscopy revealed a stenosis in the transverse colon and contrast instillation allowed characterization of the stricture and of the fistulous tract. An uncovered metal stent (WallFlex; 22–27mm×90mm; Boston Scientific, Marlborough, Massachusetts, USA) was then placed in the strictured transverse colon where the colonic fistulous orifice was located. After 3 days (to allow time for embedment of the uncovered stent in the colonic wall), a similar E-Videos