Endoscopic Therapy of Fistulas from Chronic Anastomotic Leaks

ABBREVIATIONS

CALF

chronic anastomotic leak-associated fistula

CD

Crohn’s disease

CRA

colorectal anastomosis

CRC

colorectal cancer

ECF

enterocutaneous fistula

EEF

entero-enteric fistula

ESD

endoscopic submucosal dissection

GI

gastrointestinal

IBD

inflammatory bowel disease

IPAA

ileal pouch–anal anastomosis

LAR

low anterior resection

MRI

magnetic resonance imaging

OR

odds ratio

OTSC

over-the-scope clip

RPC

restorative proctocolectomy

TTSC

through-the-scope clip

UC

ulcerative colitis

INTRODUCTION

Surgery for inflammatory bowel disease (IBD) and other benign or malignant colorectal disorders involves stapling, suturing, and anastomosis. Risk factors for anastomotic leaks include underlying disease, location of the anastomosis, anastomotic techniques, comorbidities (particularly malnutrition and anemia), exposure to radiation, and technical expertise of the surgeon. Anastomotic leaks are common in surgery for IBD or other colorectal disorders. Chronic anastomotic leaks often result in fistula formation along with abscess or inflammatory phlegmon. Most patients with fistulas from chronic anastomotic leaks are symptomatic, regardless of the presence of an abscess. Patients’ clinical presentations depend on the location and complexity of the fistula and the presence or absence of an abscess. Chronic anastomotic leak-associated fistula (CALF) in colorectal disorders can be classified as ulcerative colitis (UC) surgery-associated, Crohn’s disease (CD) surgery-associated, colorectal cancer surgery-associated, and other benign colorectal surgery-associated. While resection of anastomosis and reanastomosis with or without proximal fecal diversion has always been a treatment option, some patients with CALF, especially those who are not candidates for surgery, may benefit from endoscopic therapy. Main endoscopic treatment modalities include endoscopy-guided incision and drainage, seton placement, fistulotomy, and clipping.

DIAGNOSTIC EVALUATION

To accurately characterize CALF, we often need to evaluate patients’ presentation, cross-sectional imaging, water-soluble contrast-based imaging, and laboratory tests similar to that for presacral sinus ( Chapter 18 ). In addition, a well-planned fistulogram often provides more detailed information about fistulas (especially enterocutaneous fistula [ECF]) than cross-sectional imaging, which delineates the length and configuration of the fistula tract ( Fig. 17.1 ). Fistulogram can be performed in fluoroscopy-guided diagnostic and therapeutic endoscopy. This author also administers betadine, methylene blue, and hydrogen peroxide through the external orifice of ECF to identify the internal orifice while an endoscope is inserted in place.

ULCERATIVE COLITIS SURGERY-ASSOCIATED FISTULAS

Restorative proctocolectomy (RPC) with ileal pouch–anal anastomosis (IPAA) is the preferred surgical treatment modality for patients with UC or familial adenomatous polyposis who require colectomy. Common indications for colectomy for UC are medically refractory UC, colitis-associated neoplasia, or poor tolerance of medications. Following total proctocolectomy or failed pelvic pouch surgery, some patients may be candidates for continent ileostomy with the Kock pouch being commonly constructed than the Barnett continent intestinal reservoir. RPC is usually performed in stages in an open or laparoscopic approach. The constructive nature of RPC involves stapling, suturing, and anastomosis, which is prone to the development of leaks. The most common locations of the leak are at the anastomosis, the tip of the “J” (of the J-pouch), the stoma closure site, the vertical staple line, in the pelvic pouch, and the nipple valve in the Kock pouch. Acute leaks typically present with abscesses or sepsis, while chronic leaks usually result in the formation of the sinus or fistula ( Fig. 17.2 ) The classification of leaks in the ileal pouch is listed in Chapter 18 ( Table 18.1 ). ^,

Enterocutaneous Fistula at the StomaClosure Site

Staged pouch surgery included end ileostomy (typically after subtotal colectomy and Hartmann procedure for severe or fulminant UC) and loop ileostomy for the maturation of anastomosis at IPAA. An ileostomy is then closed with end-to-end or side-to-side anastomosis. Leaks can occur at the transverse staple line of the side-to-side anastomosis or anastomosis itself. An intra-abdominal abscess is a common adverse sequela of acute leaks. Chronic leaks in the area often present with ECF. Endoscopic clipping with through-the-scope clips (TTSCs) for smaller, fresh leaks or over-the-scope clips (OTSCs) for larger or chronic leaks with fistula ( Fig. 17.3 ). For ECF resulting from CALF, tissue debridement with a cytology brush or argon plasma coagulation should be performed before the placement of OTSC.

Fistula From the Tip of the “J”

The tip of the “J” leaks can lead to CALF in the peritoneal space, lower spine, fallopian tube, or pouch inlet ( Fig. 17.4 ), which can frequently cause significant morbidities. This author’s team reported the first case of the use of OTSCs to treat the tip of the “J” leak in the literature. Later, we used the same approach to treat CALF at the tip of the “J” along with its associated ascites. We used double OTSCs to treat CALF between the tip of the “J” and the prepouch ileum. CALF at the tip of the “J” can lead to both prepouch ileum and skin, which can be treated with endoscopic fistulotomy. Placement of TTSCs may be attempted for small leaks at the tip of the “J” ( Fig. 17.4 ). The author’s team also reported a case series of 12 consecutive patients with a leak at the tip of the “J”. Eight (66.6%) patients achieved complete closure of the leaks with six requiring a single endoscopic session and two undergoing a repeat endoscopic treatment session. Four patients (33.3%) had a persistent leak and required surgery, of whom one developed a prespinal abscess 2 weeks after the endoscopic procedure and had pouch revision surgery. This author found that tissue debridement at the orifice with a cytology brush or argon plasma coagulation may enhance the efficacy. In addition, a 12-sized OTSC (OVESCO, Tuebingen, Germany) worked best ( Fig. 17.5 ).