Endoscopic removal of an eroded surgical pledget causing liver abscesses and hepaticoduodenal fistula.

Hepaticoduodenal fistulas are rare and usually are associated with malignancy and transarterial chemoembolization. We report an interesting case of recurrent liver abscesses and hepaticoduodenal fistula caused by an eroded surgical pledget that was removed by endoscopy.

A 75-year-old woman was referred to our institution because of recurrent liver abscesses of unknown origin for 3 years. She reported profound fatigue, myalgias, right upper-quadrant pain, and intermittent high-grade fevers. She had a history of benign hepatic adenoma, had undergone a partial hepatectomy 42 years earlier, and had a gastric ulcer diagnosed 5 years before presentation. Her home medications included intravenously administered ampicillin/sulbactam. On examination, she was afebrile and obese (body mass index, 32.9). A percutaneous drainage catheter was noted in the epigastrium. A midline scar and multiple small scars from prior percutaneous drains were also noted. Laboratory data were unremarkable. CT of the abdomen and pelvis showed a percutaneous drainage catheter in the hepatic abscess, measuring 6.2 × 2.7 cm, with a concern for gastrohepatic fistula.

An EGD showed normal gastric mucosa; however, the duodenal bulb showed a fistula with purulent drainage. A fistulogram, obtained by use of a sphincterotome, demonstrated a small tract into the liver. The fistula was successfully closed by clipping after ablation of its mouth by argon plasma coagulation. The patient’s symptoms persisted.

A few weeks later, an EGD was repeated to evaluate the fistula and showed a foreign body protruding through the fistulous opening into the duodenal bulb (Video 1, available online at www.VideoGIE.org). This was noted to be a surgical pledget that had been placed during the partial hepatectomy 42 years prior. The surgical pledget was partially mobilized; however, it could not be removed even after some of the sutures were cut. After discussion with the surgeons, it was determined that an attempt to remove the surgical pledget by endoscopy would be safer than performing surgery with its potential morbidity and mortality.

EGD was repeated 1 week later. The pledget was dissected in the tissues, and multiple sutures were cut. After a prolonged procedure lasting more than 2 hours, the pledget was removed in 1 piece (Fig. 1). Our patient had significant improvement of symptoms and did not require further antibiotics. At a 5-year follow-up visit, she remained asymptomatic and did not require any further endoscopic intervention or surgery.

Figure 1

Surgical pledget removed by endoscopy. This pledget was placed during partial hepatectomy 42 years earlier.

Physicians should be aware of this rare potential adverse event of surgical pledgets, which may occur even several decades after surgery. Surgical pledgets eroding into the esophagus are reported in the literature. Endoscopic removal of the surgical pledget should be attempted, if feasible, before consideration of a major surgical procedure with potential morbidity and mortality.

Disclosure

Dr Mathew is a consultant for Boston Scientific. The other author disclosed no financial relationships relevant to this publication.