42 year old male with was detected with an incidental neuroenedocrine tumor in the 2nd part of duodenum during endoscopy for simple dyspeptic complaints. Patient was advised by us to undergo a surgery for neuroendocrine tumor based on its histopathology (grade of the tumor on biopsy), location (duodenum) & size (almost 2 cms). In view of a tricky location of the NET at the junction of 2nd & 3rd part of duodenum & need for lymph node clearance; an open surgery was suggested. Meanwhile another opinion from a different institution offered to remove the tumor through endoscopy, hence patient underwent an endoscopic procedure (CAP EMR). We had explained in great detail to the patient during our conversation why he should undergo an open surgery & not an endoscopic or laparoscopic or laparoendoscopic hybrid procedure for his situation, still the patient went ahead with the endoscopic treatment at the other institution.
Unfortunately as expected, patient had a duodenal perforation. The treating team tried to manage the complication endoscopically. However he had a duodenal leak and later an external high output duodenal fistula. Now patient came back to us with a difficult situation to handle. Patient was managed conservatively using parenteral nutrition, percutaneous drainage of collection, a nasojejunal tube (for jejunal feeds & gastric drainage) & various medications (antibiotics & octreotide). Once the fistula output dropped to nil he was started on enteral feeds through the nasojejunal tube and was discharged home. 8 weeks later multiple scans were done to confirm the healing and then all feeding and draining tubes were removed.
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