C0129 - A Unique Approach to the Management of a Colovaginal Fistula With Closure Using Esophageal Stent, Guidewire and Padlock Clip

Shannon Lee, ¹, Pragyat Futela, MBBS², Aryan Saharan, ², Sanskriti Sharma, MD³, Kumaravel Perumalsamy, MD², Duminda Suraweera, MD², Vivaik Tyagi, MD^2
1Western University of Health Science, Cerritos, CA; ²Gastro Care Institute, Lancaster, CA; ³WellStar Atlanta Medical Center, Atlanta, GA

Introduction: The risk of colonic perforation from a colonoscopy was found to be 0.03-0.8%. The risk of a fistula occurring after colonic anastomosis can be up to 10%. Currently, management has included fully covered self-expanding metal stents, endoscopic clipping with suturing, and endoscopic vacuum therapy.

Case Description/Methods: We present a 61-year-old female patient, with a past medical history of hypertension, hyperlipidemia, gout, end-stage renal disease on peritoneal dialysis and awaiting kidney transplant who underwent a screening colonoscopy and had an iatrogenic perforation of the rectosigmoid area at 20cm from the anal verge from a presumed perforated diverticulum. Management consisted of an Exploratory Laparotomy with sigmoid colectomy and primary anastomosis. Four months later, the patient presented with passing stool through her vagina, consistent with a colo-vaginal fistula. She was admitted, and she underwent colonoscopy where an EGD scope was advanced about 12-15cm to the anastomosis site; however, it was difficult to identify the site of the fistula. A 50-50% mixture of cyanoacrylate and lipid oral solution were injected submucosally. Then, a 23mmx12cm fully covered esophageal stent was deployed with subsequent single stentfix OTSC clip from OVESCO was applied. Few days after the procedure, the patient was diagnosed with pneumoperitoneum without significant peritonitis, and this was managed conservatively. A month later, she underwent flexible sigmoidoscopy with removal of stentfix clip and the stent. There was a large ulceration from the stent dilation at the anastomosis site. Due to the size of the ulcer, no intervention was performed. Her pelvic pain resolved and she stopped passing stool through her vagina, but she continued to pass air through her vagina. Subsequent barium X-ray revealed a persistent colo-vaginal fistula, and flexible sigmoidoscopy was attempted three weeks later to help close the colo-vaginal fistula. The scope was advanced into the vagina and with the help of a catheter, a 021G guidewire was passed from the vagina through the fistula into colonic anastomosis. A Padlock clip was attached to the tip of the endoscope and inserted into the rectum. The fistula was centered with the help of the guidewire into the Padlock clip and the clip was released successfully. The guidewire was then pulled out from the vagina.

Discussion: This case demonstrates a unique approach for patients with colo-vaginal fistulas for whom traditional techniques are unsuccessful.


Disclosures:


Shannon Lee, ¹, Pragyat Futela, MBBS², Aryan Saharan, ², Sanskriti Sharma, MD³, Kumaravel Perumalsamy, MD², Duminda Suraweera, MD², Vivaik Tyagi, MD². C0129 - A Unique Approach to the Management of a Colovaginal Fistula With Closure Using Esophageal Stent, Guidewire and Padlock Clip, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.