Dados do Trabalho

Título

Endoscopic treatment of rectovesical fistula after colorectal anastomosis: tube-in-tube endoscopic vacuum therapy (TT-EVT) method.

Resumo

A 56-year-old male patient underwent rectosigmoidectomy, partial cystectomy and derivative colostomy for locally advanced distal rectal adenocarcinoma, persistent after chemoradiation. On the 25th postoperative day, he presented clinical worsening and increased abdominal drain output, and was submitted to tomography with intravesical contrast infusion, which showed rectovesical fistula, communicating with surgical drain.

Rectoscopy showed a semicircumferential leak of colorectal anastomosis. Endoscopic exploration of pelvic cavity allowed removal of clots and necrosis, also cleansing with hydrogen peroxide 3% was done. As the surgical drain was in place, a tube-in-tube endoscopic vacuum therapy (TT-EVT), in intracavitary position, was performed: a guidewire was inserted through the pelvic drain and captured with grasper, then it was used to introduce a 14Fr Levine tube into surgical drain. Continuous aspiration with 125 mmHg negative pressure started. The pump was disconnected daily, so tubes could be used to irrigate cavity (1).

After 10 days, new rectoscopy showed significant reduction of leakage and pelvic cavity, with granulation tissue formation. Full thickness endoscopic clip was deployed, achieving complete closure of colorectal anastomotic fistula. The decision was to maintain intracavitary TT-EVT, draining the urinary fistula.

Ten days later, a third rectoscopy showed sustained closure of the anastomotic fistula. An ultra-slim endoscope (4.9mm) was inserted through the drain path, which was thin and long, mimicking a remaining “cystostomy”. Negative pressure was turned off and a penrose drain was left near the vesical wall.

Twenty-five days later a new tomography with intravesical contrast infusion showed well-positioned clip, without extravasation of contrast. Pelvic drain was removed and patient was discharged. Control rectoscopy confirmed defect closure and allowed reconstructive surgery.

In conclusion, tube-in-tube endoscopic vacuum therapy can be done through previously placed surgical drains, into intracavitary position. It is an effective, easy to build and low cost treatment option even when facing complex digestive fistulas.

References:
1) Lima M, Lima G, Pennacchi C, Scomparin R, De Paulo G, Martins B, et al. A simple way to deliver vacuum therapy: The tube-in-tube endoluminal vacuum therapy modification. Endoscopy. 2021;53(8):E317.

Palavras-Chave

endoscopy; rectoscopy; endoscopic vacuum therapy; digestive fistulas; anastomotic leakage; tube-intube endoscopic vacuum therapy