A 50-year-old woman with a past history of total abdominal hysterectomy presented with pneumaturia. Barium enema showed a fistulous tract between the vagina and the sigmoid colon. It was not possible to identify the fistulous tract during a colonoscopy; however, the tract of the fistula could be seen by placing a gastroscope into the vagina. Methylene blue was instilled through the tract but the entrance to the tract in the colon was still not clearly identified. A hydrophilic guidewire was therefore passed through the fistula from the vagina to the colon and grasped with a forceps ([Fig. 1]). A colonoscope with an over-the-scope clip (OTSC) mounted onto it was used to grasp the guidewire with an anchor device ([Fig. 2]) and, using a rendezvous technique, we extracted the guidewire from the vaginal side as the colonoscope was advanced up to the colonic orifice of the fistula ([Fig. 3]). Finally, the OTSC clip was released ([Video 1]). Following this procedure, the patient had complete remission of her symptoms.
Fig. 1 A hydrophilic guidewire passed through the fistula from the vagina to the colon and grasped with forceps.
Fig. 2 A colonoscope with an over-the-scope clip mounted on it was inserted into the colon and the guidewire was grasped with an anchor device.
Fig. 3 The wire was extracted from the vaginal side while the colonoscope was advanced up to the colonic orifice of the fistula using a rendezvous technique.
Video 1 Steps in the closure of a colonic fistula to the vagina: the fistulous tract in the sigmoid colon is difficult to identify; a guidewire is placed through the fistula from the vagina; the guidewire is grasped with an anchor device; the colonoscope is positioned at the fistulous orifice using a rendezvous technique; an over-the-scope clip is placed.
The OTSC device was initially designed as a mechanical method of achieving hemostasis and for the closure of small continuity solutions within the digestive tract [1]. This device provides a more lasting effect than a conventional clip owing to its higher compression force [2]. The OTSC is a useful tool in the management of digestive tract continuity solutions, although its effectiveness is greater in acute perforations and leaks [3].
On occasions, it can be difficult to identify a fistulous orifice within the digestive tract, meaning it is not possible to place an OTSC. In such cases, the instillation of methylene blue can serve as a guide to locate the colonic orifice of the fistulous tract [4]; however, this technique is not always effective. We describe an interesting alternative technique for the location of a fistulous orifice in the colonic lumen when the fistula runs between two structures that can be endoscopically instrumented.
Endoscopy_UCTN_Code_TTT_1AQ_2AG
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