PLUG AND PLAY: MANAGEMENT OF A REFRACTORY COLOCUTANEOUS FISTULA

Background
Enterocutaneous fistulae can develop as a complication of bowel surgery, inflammatory bowel disease, and malignancy. Chronic fistulae management requires a multidisciplinary approach to consider treatment options. Endoscopic interventions include covered enteric stent placement, endoscopic suturing, and endoscopic clipping, all with variable success rates. Vascular plugs are occlusion devices traditionally used to close peripheral vascular defects. Endoscopic delivery of these devices is a novel approach for definitive treatment of enterocutaneous fistulae.

Case Presentation
A 62-year-old male developed an anastomotic stricture and colocutaneous fistula after colostomy reversal following perforated diverticulitis requiring creation of a Hartmann’s pouch. The fistula persisted despite bowel rest and central parenteral nutrition, and the patient was referred for endoscopic evaluation and management.

Endoscopic Methods
A flexible sigmoidoscopy demonstrated a benign stricture at the surgical anastomosis which was confirmed as the site of the fistula with a wire introduced antegrade through the fistula tract and passed into the lumen. A lumen apposing mental stent (LAMS) was placed across the stricture to dilate the stricture and cover the fistula, with position confirmed on fluoroscopy. Follow up endoscopy one month later demonstrated a widely patent lumen after removal of the LAMS, but fluoroscopy revealed a persistent fistula which was subsequently treated with endoscopic suturing. Repeat sigmoidoscopy three months later was notable for a persistent 4 mm fistula, ultimately treated with a vascular plug. Follow-up sigmoidoscopy demonstrated no endoscopic evidence of the fistula at 4 months. The patient had no further drainage clinically 7 months after therapy.

Vascular plugs are occlusion devices traditionally used to close peripheral vascular defects. The pre-packaged vascular plug catheters are 100 cm in length. Therefore, the vascular plug must be loaded onto a separate catheter to deliver occlusion therapy endoscopically. A biliary catheter can be modified twice to accommodate the vascular plug. The tapered end of the biliary dilation catheter is cut to facilitate deployment of the vascular plug. The biliary dilation catheter is then passed down the working channel of the endoscope and the proximal end is sized again to facilitate the delivery wire. Finally, once the defect is engaged in a satisfactory position, counterclockwise rotation deploys the vascular plug.

Conclusions
This case highlights that endoscopic vascular plug therapy is a novel and promising alternative therapy to endoscopic stenting and suturing for definitive management of chronic fistulae.