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| CASE REPORT |
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| Year : 2022 | Volume
: 1
| Issue : 2 | Page : 71-75 |
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Colonic anastomotic fistula treated by endoscopic over-the-scope clip with fibrin glue
Jinpeng Zhang, Yitian Teng, Ruixia Tian, Huajian Ren
PLA Key Laboratory of Trauma and Surgical Infections, Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
| Date of Submission | 19-Jan-2023 |
| Date of Decision | 22-Jan-2023 |
| Date of Acceptance | 23-Jan-2023 |
| Date of Web Publication | 15-Feb-2023 |
Correspondence Address:
Huajian Ren
PLA Key Laboratory of Trauma and Surgical Infections, Research Institute of General Surgery, Jinling Hospital, Medical School of Nanjing University, Nanjing
China
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/wjsi.wjsi_2_23
Enterocutaneous fistula is a severe complication of gastrointestinal surgery, often associated with abdominal infection, bleeding, malnutrition, and multiple organ dysfunction. Among the early stages of enterocutaneous fistula, the active promotion of spontaneous healing of enterocutaneous fistula is crucial for the treatment of enterocutaneous fistula. Herein, we present a case of enterocutaneous fistula occurring in a 55-year-old Chinese male patient. The patient was operated on by sigmoid diverticulum perforation and underwent partial sigmoid resection and colostomy. Four months later and stoma reversal was done, after which the incision went through repeat infection. He presented to the outpatient department with a sinus tract within the median abdominal incision and pus in abdominal drainage. He was then diagnosed with a colonic anastomotic fistula after computer tomography and fistulography. The successful closure of the fistula confirmed by colonogram was achieved within 2 weeks by the treatment of over-the-scope clip (OTSC) combined with fibrin glue. Our case shows that the approaches of OTSC and fibrin glue are expected to be a promising and novel strategy for treating enterocutaneous fistulas.
Keywords: Abdominal infection, colonic diverticulum, intestinal fistula, over-the-scope clip
How to cite this article:
Zhang J, Teng Y, Tian R, Ren H. Colonic anastomotic fistula treated by endoscopic over-the-scope clip with fibrin glue. World J Surg Infect 2022;1:71-5 |
| Introduction | |  |
Despite technical advances in gastroenterological surgery, enterocutaneous fistula remains a significant challenge during the postoperative period, often associated with abdominal infection, bleeding, malnutrition, and multiple organ dysfunction.[1] Operative intervention is required for the majority of enterocutaneous fistulas. Of great importance is that one considers initial management equally critical in determining the outcome, including early detection, assessment, and nutritional support.[2] With adequate drainage and controlled infection, an intractable internal fistula may develop into a controllable ductal fistula, which could be subsequently closed. Here we report a thought-provoking case of colonic anastomotic fistula successfully treated with endoscopic anastomotic clips and fibrin glue, proposing the combined application of over-the-scope clip (OTSC) and fibrin glue for the treatment of enterocutaneous fistula.
| Case Report | | |
Patient information
The patient was admitted to the hospital on September 1, 2020, with a history of left inguinal hernia and hypertension. On December 22, 2019, the patient presented with persistent abdominal pain. A computer tomography (CT) examination of the whole abdomen showed that the sigmoid colon was thickened and blurred, and the surrounding mesentery was dense and blurred with gas shadow. It was diagnosed with “sigmoid colon perforation.” The emergency department performed a laparotomy. During the surgical operation, a little pus was seen in the abdominal cavity, a hard mass was located at the lower end of the sigmoid colon, and “partial sigmoid colectomy + colostomy” was performed. The pathological findings revealed the presence of ectopic mucosa with the cyst formation in the sigmoid colon of the patient. The cyst was infected, ruptured and accompanied by localized mesenteric abscess formation. On March 25, 2020, the patient underwent “sigmoidostomy closure operation,” but the postoperative incision was poorly healed with repeated pus exudation and cared with dressing changes and catheter drainage of incision. After treatment, such as debridement and sutures, pus still flowed out of the incision.
Examination
The patient was observed to have an old surgical scar in the middle of the abdomen, and a sinus with a drainage tube in the middle part of the surgical incision. The drainage tube was located at the original surgical site, and the drainage fluid was purulent. The left lower abdomen was slightly firm to palpation, with dull pressure pain but without rebound pain [Figure 1].
Abdominal intestinal iodine hydrographic CT (500 ml of 3% iohexol solution orally) suggests the formation of a pus cavity in the left lower abdomen with a visible drainage tube.
Abdominal sinus tract imaging suggested that the abdominal pus cavity, sigmoid colon, and rectum were sequentially visualized when contrast was injected through the orifice of the median abdominal sinus tract. Injecting contrast into the left abdominal drainage tube, the drainage tube can be seen connecting to the sigmoid colon. Colonography hints: when contrast was injected through the anus, the rectum, sigmoid colon, and descending colon were sequentially visualized, and the sigmoid colon was seen to spill contrast [Figure 2]. | Figure 2: Imaging findings after admission. (a and b) Abscess cavity in the left lower abdomen. (c) Contrast injected through the fistula and sigmoid colon can be seen. (d) Contrast agent is injected through the anus, and the contrast agent is seen to leak from the anastomosis of the sigmoid colon
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Colonoscopy (2020-9-10) suggested that a colonic anastomosis was visible approximately 15 cm from the anal verge through the bowel; granulation growth and several anastomotic staples were visible on the left anterior wall of the anastomosis. The injection of melanin solution confirmed the fistula through the sinus tract in the abdominal wall, through which blue fluid was seen to leak, followed by the removal of the anastomotic staples. Dependent on continuous double cannula irrigation, the abscess cavity becomes significantly smaller and the drainage fluid is gradually clear [Figure 3]. | Figure 3: Abdominal radiograph. After continuous double cannula irrigation, the abscess cavity becomes significantly smaller
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Diagnosis and treatment
After admission, the patient was treated with fasting, acid suppression, and parenteral nutritional support. Routine laboratory tests carried out. The sigmoid colonic anastomotic fistula was diagnosed by sinus imaging and abdominal CT.
With the use of fasting, acid suppression, parenteral nutritional support, and double-cannula drainage and flushing, the patient's pus cavity was significantly reduced compared with that on admission [Figure 4]. | Figure 4: Results of colonoscopy. (a) Colonoscopy shows a fistula 15 cm from the margin. (b) Inject meilan through the fistula. (c) Remove the perifistula anastomosis nail and debride the mucosa around the fistula. (d) Over-the-scope clip clips the fistula
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This colonoscopy suggested that a colonic anastomosis was visible approximately 15 cm from the anal verge through the bowel. Moreover, granulation tissues and several anastomotic staples were visible in the left anterior wall of the anastomosis. The anastomotic staples were removed, the mucosa surrounding the fistula was cauterized with argon plasma coagulation, and the fistula was clamped closed with OTSC (14/6t). Melanotic fluid was again injected through the abdominal wall sinus tract, and no blue fluid was leaked out [Figure 5]. | Figure 5: Patient outcome. (a) The fistula has been significantly narrowed on angiography. (b) Fibrin glue. (c and d) Computed tomography shows no significant exudation around the fistula
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The abdominal radiography showed that the OTSC clip was in place. Two days later, the image of the sinus showed that the original sinus tract had been significantly reduced compared with that before OTSC treatment. However, a small amount of contrast agent could still be seen entering the sigmoid colon lumen through the internal fistula. To further promote healing of the fistula, fibrin glue was injected through the external skin fistula to seal the fistula. After 2 weeks of continuous dressing exchange at the external fistula, continued fasting, acid suppression, and parenteral nutritional support therapy, a repeat abdominal CT showed no significant tissue exudation around the fistula [Figure 6], and the patient was gradually translated to enteral nutritional support therapy through nasogastric tube, which was considered stable state of disease. Therefore, the patient was discharged home with an enteral nutritional support therapy. | Figure 6: Test result of the patient after 3 months. (a) External fistula healing at 3 months follow-up after discharge. (b and c) No contrast agent leaks from the colon
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Outcomes
The patient was considered to have a healed sigmoid colonic anastomotic fistula and gradually translated to transoral feeding.
| Discussion | | |
As a severe complication of gastroenterological surgery, early identification and diagnosis of fistula remain a significant challenge in the clinical scenario. Type II incisions are the most common in gastroenterological surgery, and postoperative incisional infection appears in approximately 4%–10% of patients who underwent surgery.[3] The incidence is even higher in underdeveloped countries and regions.[4],[5] Therefore, when confronted with incisional exudation and recurrent infections during the postoperative period, surgeons tend to consider such symptoms as a manifestation of superficial incisional infection, ignoring the possibility of a fistula. To promote early identification of fistula, cryptogenic postoperative fever, peritonitis, or prolonged incision healing should be considered warning signs that require further observation of clinical indicators, including temperature fluctuation, calcitoninogen, C-reactive protein, as well as drainage fluid. Moreover, when drainage appears to be ineffective for incision healing, incisional exudation, and drainage fluid amylase specimen analysis, abdominal CT scans and epistolography should be done to help identify fistula in the early stage.
The usual treatment of fistula/enterocutaneous fistulas includes three phases: drainage, autonomous adhesion loosening, and definitive surgery, which is time-consuming and causes financial hardship. As reported above, we notice that in some cases, with successful control of infection in the early stage and effective conservative treatment, fistula closure can also be achieved with the hydro impression, adhesive plugging, and OTSC after the inflammatory edema subsides, which may provide a more efficient therapeutic strategy.[6]
The safety and efficacy of the OTSC in treating alimentary tract perforation and hemorrhage have been confirmed by clinical trials.[7] One study showed that the anatomical locations of OTSC placement were located in the colon, duodenum, stomach, esophagus, rectum, and small intestine, respectively.[8] Conventionally, the success rate of OTSC for acute perforation and bleeding is approximately 85%. This figure rises to 90% in acute endoscopic procedure-related perforations, which suggests that OTSC can potentially replace surgery, achieve efficient hemostasis and reduce postoperative complications. However, the success rate of using OTSC to close intestinal fistulas is <50%. The low success rate may be because the final closure of the fistula depends on the grasping of the involved tissue by the forceps. In acute perforation and hemorrhage cases, fresh serosal and mucosal tissue enables a full grasp and better recovery. In contrast, chronic fibrosis is commonly seen in gastroenterological fistulas due to tissue erosion by intestinal fluid, obstructing OTSC and wound healing.[9] Therefore, it is critical to keep the fistula and surrounding tissues fresh before OTSC. Placing a double cannula for irrigation is preferable, and nutritional improvement and complete fasting are equally necessary.
As for fibrin glue, it can be applied to ductal fistulas with a diameter of <1 cm, low output of digestive juice, no absence adjacent to it, and no foreign substances within the sinus.[10] Previous studies have reported the application of endoscopy with fibrin glue plugging, aiming to tackle obstructive factors of enterocutaneous fistula closure, such as anastomotic staples, threads, foreign bodies, necrotic abscesses, and mucosal ectasia.[11] Before fibrin glue plugging, sinus tract imaging is required to claim details on fistula diameter, location, morphology, and surrounding abscesses. Patients with radiative enteritis and active Crohn's disease should be excluded from the population suitable for fibrin glue.
We illustrate an approach for closing the enterocutaneous fistula with OTSC and fibrin glue. More research about clip structures, patient population selection, and therapeutic plans is needed to provide more reliable guidance for clinical practice.[12]
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 8. | Bartell N, Bittner K, Kaul V, Kothari TH, Kothari S. Clinical efficacy of the over-the-scope clip device: A systematic review. World J Gastroenterol 2020;26:3495-516. |
| 9. | Honegger C, Valli PV, Wiegand N, Bauerfeind P, Gubler C. Establishment of Over-The-Scope-Clips (OTSC ®) in daily endoscopic routine. United European Gastroenterol J 2017;5:247-54. |
| 10. | Wang XB, Ren JA, Li JS, et al. Closure of enterocutaneous fistulas using fibrin sealant. Med J Chin PLA 2004;29:164-5. |
| 11. | Rábago LR, Ventosa N, Castro JL, Marco J, Herrera N, Gea F. Endoscopic treatment of postoperative fistulas resistant to conservative management using biological fibrin glue. Endoscopy 2002;34:632-8. |
| 12. | Ou YH, Kong WF, Li LF, Chen PS, Deng SH, He FJ, et al. Methods for endoscopic removal of over-the-scope clip: A systematic review. Can J Gastroenterol Hepatol 2020;2020:5716981. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
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