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Endoscopic management of colocutaneous fistula in a morbidly obese woman (with video)
Endoscopic management of colocutaneous fistula in a morbidly obese woman (with video) Rajasekhara R. Mummadi, MD, Jeffrey R. Groce, MD, Gottumukkala S. Raju, MD, DM, FRCP (Lon), FACP, FACG, FASGE, Guillermo Gomez, MD Galveston, Texas, USA
Colocutaneous fistula is a disabling complication of postoperative anastomotic colonic leak. Persistent fistula is managed by surgical revision.1 Endoluminal closure may be an option worth pursuing in those who are not candidates for surgery. We report endoscopic closure of a chronic colocutaneous fistula in a morbidly obese patient who was not a candidate for surgical revision.
CASE REPORT A 56-year-old woman with morbid obesity (390 lbs) and obstructive sleep apnea underwent a right hemicolectomy for colon cancer. Her postoperative course was complicated by a pulmonary embolism. Anastomotic leakage resulted in a large intra-abdominal abscess, which led to a colocutaneous fistula (Fig. 1). After initial management in the intensive care unit with nothing by mouth, parenteral nutrition, and antibiotics, she recovered, but the daily output of pus and feces from the fistula varied from 50 to 100 mL for 6 months. Due to morbid obesity and a recent pulmonary embolism, surgery was deferred; endoscopic therapy was recommended. Informed consent was obtained after we showed the patient and her husband a video of our experimental endoscopic clip closure of a large colon perforation, resulting in a leak-proof sealing,2 and explained to them the emerging role of endoscopy in the management of GI leaks. The patient was admitted to the hospital for colon cleansing with a polyethyleneglycol-based electrolyte solution. A pediatric colonoscope (Pentax Medical, Montvale, NJ) fitted with a band ligator cap (Wilson-Cook, WinstonSalem, NC) was used. A 1-cm fistula was seen adjacent to the staples at the hepatic flexure. A small amount of pus poured out after probing it with a catheter (Fig. 2). After cauterizing the edges with a 7F gold probe (Boston Scientific, Natick, Mass), 4 Resolution clips (Boston Scientific) were applied to approximate the defect (Video 1, available online at www.giejournal.org). The fistula output decreased dramatically, from 50 mL to 2 mL per day within 24 hours. During the clinic visit at 3 months, the fistula was found to be healed. Subsequently, the scab broke down, with a discharge of a few mL of pus, and required 3 courses of broad-spectrum antibiotics. After 6 months, the wound healed completely without any further breaks of the scab, except for a recent breakdown of the scab at 12 months with a discharge of small amounts of blood, which was treated with broad-spectrum antibiotics. www.giejournal.org
Figure 1. CT scan of the abdomen demonstrating colocutaneous fistula (arrow).
Figure 2. Endoscopic view of the colocutaneous fistula, probing with a catheter.
DISCUSSION Endoscopic clip application is successful in the closure of esophageal and gastric perforations and fistulas.3-6 Recent experimental studies in a porcine model demonstrated that various types of colon perforations can be closed by endoscopic clip and suture application.2,7-10 Our literature search identified a few cases of colon perforations and fistulas that were managed successfully by endoluminal closure.11 These include cases of colon perforations complicating colonoscopy and snare resection, colovesical fistula complicating diverticulitis, colocutaneous fistula Volume 67, No. 7 : 2008 GASTROINTESTINAL ENDOSCOPY 1207
Brief Reports
complicating perforated appendix, and necrotizing pancreatitis.12-16 Encouraged by these reports from other centers as well as our own preliminary experience in the laboratory, we decided to offer this novel endoscopic therapy to our patient, which has resulted in a dramatic reduction in the fistula output, from 50 to 100 mL to a few mL immediately after the closure, with eventual healing of the fistula after a few weeks. Our case demonstrates the feasibility of endoluminal closure of chronic colocutaneous fistula complicating anastomotic leak after colon resection. In contrast to the experimental setup, in which clip closure of acute perforations is fairly simple to do, closure of chronic fistulas requires attention to several factors. First, fistulous opening may be hard to find with a conventional endoscope; a cap-fitted endoscope may help to retract the edges and visualize the opening.17,18 Second, roughing up of the edges of the fistula with a brush or cautery may improve healing after tissue approximation.19 Third, the edges of a chronic fistula are edematous and may not be easy to approximate with clips. Multiple sessions may be required.20 In our case, because the output decreased dramatically to a couple of milliliters, no further interventions were undertaken and the tract was allowed to heal. Although the scab periodically breaks down (with a small amount of bloody discharge but without any feces or pus), we believe that endoscopic therapy helped in the healing of the fistula. In summary, endoscopic closure of colocutaneous fistula complicating anastomotic leak is an option worth pursuing and requires further investigation. DISCLOSURE The following authors report that they have no disclosures relevant to this publication: R. R. Mummadi, J. R. Groce, G. Gomez. The following author has disclosed actual or potential conflicts: G. S. Raju has received research support from Boston Scientific, Inc, Pentax Medical, Inc, and Ethicon Endosurgical, Inc.
5. Minami S, Gotoda T, Ono H, et al. Complete endoscopic closure of gastric perforation induced by endoscopic resection of early gastric cancer using endoclips can prevent surgery (with video). Gastrointest Endosc 2006;63:596-601. 6. Groce JR, Raju GS, Hewlett A, et al. Endoscopic clip closure of a gastric staple-line dehiscence (with video). Gastrointest Endosc 2007;65: 321-2. 7. Raju GS, Ahmed I, Shibukawa G, et al. Endoluminal clip closure of a circular full-thickness colon resection in a porcine model (with videos). Gastrointest Endosc 2007;65:503-9. 8. Raju GS, Ahmed I, Xiao SY, et al. Controlled trial of immediate endoluminal closure of colon perforations in a porcine model by use of a novel clip device (with videos). Gastrointest Endosc 2006;64: 989-97. 9. Raju GS, Pham B, Xiao SY, et al. A pilot study of endoscopic closure of colonic perforations with endoclips in a swine model. Gastrointest Endosc 2005;62:791-5. 10. Raju GS, Shibukawa G, Ahmed I, et al. Endoluminal suturing may overcome the limitations of clip closure of a gaping wide colon perforation (with videos). Gastrointest Endosc 2007;65:906-11. 11. Raju GS, Gajula L. Endoclips for GI endoscopy. Gastrointest Endosc 2004;59:267-79. 12. Mana F, De Vogelaere K, Urban D. Iatrogenic perforation of the colon during diagnostic colonoscopy: endoscopic treatment with clips. Gastrointest Endosc 2001;54:258-9. 13. Yoshikane H, Hidano H, Sakakibara A, et al. Endoscopic repair by clipping of iatrogenic colonic perforation. Gastrointest Endosc 1997;46: 464-6. 14. Jacobson BC, Briggs DR, Carr-Locke DL. Endoscopic closure of a colovesical fistula. Gastrointest Endosc 2001;54:248-50. 15. Lee SO, Jeong YJ. Colonoscopic clipping of fecal fistula that occurred as a postoperative complication in patients with perforated appendicitis: two case reports. Gastrointest Endosc 2001;54:245-7. 16. Familiari P, Macri A, Consolo P, et al. Endoscopic clipping of a colocutaneous fistula following necrotizing pancreatitis: case report. Dig Liver Dis 2003;35:907-10. 17. Yap CK, Ng HS. Cap-fitted gastroscopy improves visualization and targeting of lesions. Gastrointest Endosc 2001;53:93-5. 18. Warneke RM, Walser E, Faruqi S, et al. Cap-assisted endoclip placement for recurrent ulcer hemorrhage after repeatedly unsuccessful endoscopic treatment and angiographic embolization: case report. Gastrointest Endosc 2004;60:309-12. 19. Adler DG, McAfee M, Gostout CJ. Closure of an esophagopleural fistula by using fistula tract coagulation and an endoscopic suturing device. Gastrointest Endosc 2001;54:652-3. 20. Raymer GS, Sadana A, Campbell DB, et al. Endoscopic clip application as an adjunct to closure of mature esophageal perforation with fistulae. Clin Gastroenterol Hepatol 2003;1:44-50.
REFERENCES 1. Soeters PB, de Zoete JP, Dejong CH, et al. Colorectal surgery and anastomotic leakage. Dig Surg 2002;19:150-5. 2. Raju GS, Ahmed I, Brining D, et al. Endoluminal closure of large perforations of colon with clips in a porcine model (with video). Gastrointest Endosc 2006;64:640-6. 3. Raju GS, Thompson C, Zwischenberger JB. Emerging endoscopic options in the management of esophageal leaks (with videos). Gastrointest Endosc 2005;62:278-86. 4. Tsunada S, Ogata S, Ohyama T, et al. Endoscopic closure of perforations caused by EMR in the stomach by application of metallic clips. Gastrointest Endosc 2003;57:948-51.
1208 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 7 : 2008
Center for Endoscopic Research, Training, and Innovation (CERTAIN) (R.R.M., J.R.G., G.S.R.), Department of General Surgery (G.G.) University of Texas Medical Branch, Galveston, Texas, USA. Reprint requests: Rajasekhara R Mummadi, MD, Center for Endoscopic Research, Training, and Innovation (CERTAIN), University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555-0764. Copyright ª 2008 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2007.10.036
www.giejournal.org
Colocutaneous fistula is a disabling complication of postoperative anastomotic colonic leak. Persistent fistula is managed by surgical revision.1 Endoluminal closure may be an option worth pursuing in those who are not candidates for surgery. We report endoscopic closure of a chronic colocutaneous fistula in a morbidly obese patient who was not a candidate for surgical revision.
CASE REPORT A 56-year-old woman with morbid obesity (390 lbs) and obstructive sleep apnea underwent a right hemicolectomy for colon cancer. Her postoperative course was complicated by a pulmonary embolism. Anastomotic leakage resulted in a large intra-abdominal abscess, which led to a colocutaneous fistula (Fig. 1). After initial management in the intensive care unit with nothing by mouth, parenteral nutrition, and antibiotics, she recovered, but the daily output of pus and feces from the fistula varied from 50 to 100 mL for 6 months. Due to morbid obesity and a recent pulmonary embolism, surgery was deferred; endoscopic therapy was recommended. Informed consent was obtained after we showed the patient and her husband a video of our experimental endoscopic clip closure of a large colon perforation, resulting in a leak-proof sealing,2 and explained to them the emerging role of endoscopy in the management of GI leaks. The patient was admitted to the hospital for colon cleansing with a polyethyleneglycol-based electrolyte solution. A pediatric colonoscope (Pentax Medical, Montvale, NJ) fitted with a band ligator cap (Wilson-Cook, WinstonSalem, NC) was used. A 1-cm fistula was seen adjacent to the staples at the hepatic flexure. A small amount of pus poured out after probing it with a catheter (Fig. 2). After cauterizing the edges with a 7F gold probe (Boston Scientific, Natick, Mass), 4 Resolution clips (Boston Scientific) were applied to approximate the defect (Video 1, available online at www.giejournal.org). The fistula output decreased dramatically, from 50 mL to 2 mL per day within 24 hours. During the clinic visit at 3 months, the fistula was found to be healed. Subsequently, the scab broke down, with a discharge of a few mL of pus, and required 3 courses of broad-spectrum antibiotics. After 6 months, the wound healed completely without any further breaks of the scab, except for a recent breakdown of the scab at 12 months with a discharge of small amounts of blood, which was treated with broad-spectrum antibiotics. www.giejournal.org
Figure 1. CT scan of the abdomen demonstrating colocutaneous fistula (arrow).
Figure 2. Endoscopic view of the colocutaneous fistula, probing with a catheter.
DISCUSSION Endoscopic clip application is successful in the closure of esophageal and gastric perforations and fistulas.3-6 Recent experimental studies in a porcine model demonstrated that various types of colon perforations can be closed by endoscopic clip and suture application.2,7-10 Our literature search identified a few cases of colon perforations and fistulas that were managed successfully by endoluminal closure.11 These include cases of colon perforations complicating colonoscopy and snare resection, colovesical fistula complicating diverticulitis, colocutaneous fistula Volume 67, No. 7 : 2008 GASTROINTESTINAL ENDOSCOPY 1207
Brief Reports
complicating perforated appendix, and necrotizing pancreatitis.12-16 Encouraged by these reports from other centers as well as our own preliminary experience in the laboratory, we decided to offer this novel endoscopic therapy to our patient, which has resulted in a dramatic reduction in the fistula output, from 50 to 100 mL to a few mL immediately after the closure, with eventual healing of the fistula after a few weeks. Our case demonstrates the feasibility of endoluminal closure of chronic colocutaneous fistula complicating anastomotic leak after colon resection. In contrast to the experimental setup, in which clip closure of acute perforations is fairly simple to do, closure of chronic fistulas requires attention to several factors. First, fistulous opening may be hard to find with a conventional endoscope; a cap-fitted endoscope may help to retract the edges and visualize the opening.17,18 Second, roughing up of the edges of the fistula with a brush or cautery may improve healing after tissue approximation.19 Third, the edges of a chronic fistula are edematous and may not be easy to approximate with clips. Multiple sessions may be required.20 In our case, because the output decreased dramatically to a couple of milliliters, no further interventions were undertaken and the tract was allowed to heal. Although the scab periodically breaks down (with a small amount of bloody discharge but without any feces or pus), we believe that endoscopic therapy helped in the healing of the fistula. In summary, endoscopic closure of colocutaneous fistula complicating anastomotic leak is an option worth pursuing and requires further investigation. DISCLOSURE The following authors report that they have no disclosures relevant to this publication: R. R. Mummadi, J. R. Groce, G. Gomez. The following author has disclosed actual or potential conflicts: G. S. Raju has received research support from Boston Scientific, Inc, Pentax Medical, Inc, and Ethicon Endosurgical, Inc.
5. Minami S, Gotoda T, Ono H, et al. Complete endoscopic closure of gastric perforation induced by endoscopic resection of early gastric cancer using endoclips can prevent surgery (with video). Gastrointest Endosc 2006;63:596-601. 6. Groce JR, Raju GS, Hewlett A, et al. Endoscopic clip closure of a gastric staple-line dehiscence (with video). Gastrointest Endosc 2007;65: 321-2. 7. Raju GS, Ahmed I, Shibukawa G, et al. Endoluminal clip closure of a circular full-thickness colon resection in a porcine model (with videos). Gastrointest Endosc 2007;65:503-9. 8. Raju GS, Ahmed I, Xiao SY, et al. Controlled trial of immediate endoluminal closure of colon perforations in a porcine model by use of a novel clip device (with videos). Gastrointest Endosc 2006;64: 989-97. 9. Raju GS, Pham B, Xiao SY, et al. A pilot study of endoscopic closure of colonic perforations with endoclips in a swine model. Gastrointest Endosc 2005;62:791-5. 10. Raju GS, Shibukawa G, Ahmed I, et al. Endoluminal suturing may overcome the limitations of clip closure of a gaping wide colon perforation (with videos). Gastrointest Endosc 2007;65:906-11. 11. Raju GS, Gajula L. Endoclips for GI endoscopy. Gastrointest Endosc 2004;59:267-79. 12. Mana F, De Vogelaere K, Urban D. Iatrogenic perforation of the colon during diagnostic colonoscopy: endoscopic treatment with clips. Gastrointest Endosc 2001;54:258-9. 13. Yoshikane H, Hidano H, Sakakibara A, et al. Endoscopic repair by clipping of iatrogenic colonic perforation. Gastrointest Endosc 1997;46: 464-6. 14. Jacobson BC, Briggs DR, Carr-Locke DL. Endoscopic closure of a colovesical fistula. Gastrointest Endosc 2001;54:248-50. 15. Lee SO, Jeong YJ. Colonoscopic clipping of fecal fistula that occurred as a postoperative complication in patients with perforated appendicitis: two case reports. Gastrointest Endosc 2001;54:245-7. 16. Familiari P, Macri A, Consolo P, et al. Endoscopic clipping of a colocutaneous fistula following necrotizing pancreatitis: case report. Dig Liver Dis 2003;35:907-10. 17. Yap CK, Ng HS. Cap-fitted gastroscopy improves visualization and targeting of lesions. Gastrointest Endosc 2001;53:93-5. 18. Warneke RM, Walser E, Faruqi S, et al. Cap-assisted endoclip placement for recurrent ulcer hemorrhage after repeatedly unsuccessful endoscopic treatment and angiographic embolization: case report. Gastrointest Endosc 2004;60:309-12. 19. Adler DG, McAfee M, Gostout CJ. Closure of an esophagopleural fistula by using fistula tract coagulation and an endoscopic suturing device. Gastrointest Endosc 2001;54:652-3. 20. Raymer GS, Sadana A, Campbell DB, et al. Endoscopic clip application as an adjunct to closure of mature esophageal perforation with fistulae. Clin Gastroenterol Hepatol 2003;1:44-50.
REFERENCES 1. Soeters PB, de Zoete JP, Dejong CH, et al. Colorectal surgery and anastomotic leakage. Dig Surg 2002;19:150-5. 2. Raju GS, Ahmed I, Brining D, et al. Endoluminal closure of large perforations of colon with clips in a porcine model (with video). Gastrointest Endosc 2006;64:640-6. 3. Raju GS, Thompson C, Zwischenberger JB. Emerging endoscopic options in the management of esophageal leaks (with videos). Gastrointest Endosc 2005;62:278-86. 4. Tsunada S, Ogata S, Ohyama T, et al. Endoscopic closure of perforations caused by EMR in the stomach by application of metallic clips. Gastrointest Endosc 2003;57:948-51.
1208 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 7 : 2008
Center for Endoscopic Research, Training, and Innovation (CERTAIN) (R.R.M., J.R.G., G.S.R.), Department of General Surgery (G.G.) University of Texas Medical Branch, Galveston, Texas, USA. Reprint requests: Rajasekhara R Mummadi, MD, Center for Endoscopic Research, Training, and Innovation (CERTAIN), University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555-0764. Copyright ª 2008 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2007.10.036
www.giejournal.org