Successful endoscopic treatment of an appendicocutaneous fistula using endoloops

An appendicocutaneous fistula is a rare complication of appendectomy [1]. Moreover, the fistula can persist [2]. A 52-year-old man presented to our department with a 3-month history of purulent abdominal wall sinus that developed after appendectomy 3 months ago. Abdominal wall radiography revealed an abdominal wall fistula connecting with the ileocecal region ( [Fig.1]). Under colonoscopy, we identified the swollen and purulent appendix stump with black stitching residue ([Video 1]). After repeated washing of the appendix stump ([Video 1]), milky pus remained around the stitching residue ([Fig. 2]). Using grasping forceps, we easily removed the stitching residue ([Video 1]). Saline solution with methylene blue was injected from the ostium of the abdominal wall fistula, and the inlet of the fistula was detected at the appendix stump ([Fig. 3]). Normal saline was then injected repeatedly from the abdominal outlet of the sinus to wash the fistula ([Video 1]). After washing, we released a nylon ring into the ileocecal region ([Video 1]). Eight clips were used to fasten the nylon ring around the inlet of the fistula at the appendix stump ([Video 1]). We then tightened and released the nylon ring ([Fig. 4]). Methylene blue dye was again injected from the abdominal wall sinus outlet ([Video 1]); the dye was refluxed back, and the ileocecal region did not show methylene blue. We found two outlets of the fistula ([Video 1]). Two drainage tubes were placed at the outlets ([Video 1]). Two weeks later, we noted that the inlet and the outlets of the fistula were healing ([Fig. 5]). The use of endoscopic endoloops is a new strategy to promote healing of an appendicocutaneous fistula without surgery.

Fig. 1 Abdominal wall radiograph showing the abdominal wall fistula connected with the ileocecal region.

Video 1 Appendicocutaneous fistula treated using endoscopic endoloops.

Fig. 2 Milky pus around the stitching residue.

Fig. 3 Inlet of the fistula at the appendix stump.

Fig. 4 Closing of the fistula inlet using endoloops.

Fig. 5 Inlet of the fistula healing 2 weeks after treatment.

Endoscopy_UCTN_Code_CPL_1AJ_2AG

Publication History

Article published online:
15 April 2020

• References

• 1 Brünagel G, Decker P, Hirner A. Delayed appendico-cutaneous fistula – a rare complication of simple abdominal drainage. Zentralbl Chir 1996; 121: 67-69
• 2 Shamim M, Haider SA, Iqbal SA. Persistent appendiceal faecal fistula following a complicated open appendicectomy. J Pak Med Assoc 2009; 59: 181-183