1690 Management of Non-Malignant Enterocutaneous Fistula Using Fully Covered Stent

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INTRODUCTION: Postoperative enterocutaneous fistula (ECF) has a reported prevalence of 3.6% in general surgery, and up to 35% in Crohn disease-related surgery. ECFs can be of low-output, drain < 200 mL/day, or of high-output, drain > 500 mL/day, which unlikely to heal spontaneously. ECFs can cause metabolic disturbances, fluid loss, and malnutrition. CASE DESCRIPTION/METHODS: Case 1: A 54-year-old man with a history of colonic transmural necrosis status post multiple surgeries and end transverse colostomy placement, presented with a two-week history of passing stool from the lateral aspect of his peristomal incision, consistent with enterocutaneous fistula. The 2 fistulae ends were seen on the skin, laterally to the stoma (Figure 2c), and both other ends were identified in the stoma lumen. CT fistulogram confirmed the fistulae. After advancing the endoscope into the stoma, a 2 cm friable stenosis was seen (Figure 1a). The fistulae tracts were treated with silver nitrate and were injected with fibrin glue. A 20 mm × 6 cm fully-covered stent was placed (Figure 1b) and sutured in place. A month later the fistulae had healed (Figure 2d), with no recurrence reported. Case 2: A 64-year-old man with a history of metastatic mucinous appendiceal cancer status post multiple abdominal surgeries, referred for his recurrent ECF. CT scan showed air tracking outside the colon at the level of the cutaneous fistula site. Water-soluble contrast pushed through the rectum showed an occlusion with contrast extravasation is seen in the fistula (Figure 3e). Sigmoidoscopy confirmed the site of obstruction and the area of leakage. A fully covered stent was placed to relieve the obstruction and cover the fistula (Figure 3f). Initially, the fistula output resolved, but when the stent was removed a month later, the fistula output returned. So, a stent was placed again and was sutured to the colon. The patient is now asymptomatic and having normal bowel movements. DISCUSSION: ECF can cause significant morbidity and affect the quality of life. Surgical repair of ECF has a recurrence rate as high as 36% and is associated with high mortality especially in malnourished patients. Thus, endoscopic intervention using fully-covered stents can be helpful in healing the fistulae. In these 2 cases, the placement of a fully-covered stent relieved the coexisting obstruction, diverted the flow away from the fistula, and simultaneously covered the fistula end. The patients experienced relief of fistula symptoms and avoided them major surgical intervention. Watch the video: http://bit.ly/30BIvtw.