RETROGRADE ENDOSCOPIC ULTRASOUND-GUIDED ENTERO-ENTEROSTOMY USING A LUMEN-APPOSING METAL STENT FOR THE MANAGEMENT OF A HIGH-OUTPUT ENTEROCUTANEOUS FISTULA AND ILEAL STRICTURE IN A COMPLEX SURGICAL ABDOMEN

Background
A 26-year-old male sustained significant traumatic thoracoabdominal injuries following a gunshot. He underwent several laparotomies, small bowel resections, a partial hepatectomy and an extended left hemicolectomy with an end-colostomy formation. An abdominal flap was required to close the abdomen.

Case Presentation
The patient subsequently developed a high-output enterocutaneous fistula (ECF) and loss of colostomy output. CT imaging confirmed an ECF from the ileum to the anterior abdominal wall and a severe ileal stricture distal to the fistula. In the context of his complex surgical abdomen and proximity of the ECF to the abdominal flap, surgical re-intervention was deemed to be high-risk. He was placed on total parenteral nutrition and referred for endoscopic management.

Endoscopic Methods
Under fluoroscopic guidance, we injected methylene blue and contrast dye from the skin side of the ECF. A dilated segment of small bowel was filled, with no downstream passage of contrast. Retrograde ileoscopy was performed with a pediatric colonoscope via the patient’s colostomy. Approximately 90 cm from the ileocecal valve (ICV), we encountered a benign enteric stenosis that could not be traversed. Contrast was injected, with fluoroscopy revealing a 10 cm long tortuous stenosis, extending to the previously filled loop of small bowel. Given the length, character and position of the stricture, endoscopic balloon dilation and enteral stenting were technically infeasible.

We proceeded to retrograde endoscopic ultrasound (EUS)-guided entero-enterostomy creation. With the aid of a guidewire, and under endoscopic, fluoroscopic and endosonographic guidance, a linear echoendoscope was advanced into the ileum via the colostomy, cecum and ICV. Approximately 50 cm from the ICV, we identified an adjacent dilated loop of small bowel. Water was instilled through the ECF, with the endosonographic view demonstrating filling, thus indicating this location to be upstrea m from the ECF. A 19-gauge needle was punctured through, with subsequent aspiration of methylene blue. We then created an EUS-guided entero-enterostomy using a cautery-enhanced 15 mm lumen-apposing metal stent. Passage of methylene blue and contrast through the stent confirmed accurate deployment. With both the ECF and stricture bypassed, the patient’s colostomy output returned and ECF output diminished.

Conclusions
Electrocautery-enhanced lumen apposition with metal stenting is well established. It can facilitate the formation of an anchored anastomosis across non-adherent luminal structures in a single-step fashion. Herein, we have reported a novel application of this technique in the management of a complex post-surgical trauma patient with a high-output ECF and a deep enteric stenosis.