Rendezvous technique assisted by anchor device: a new trick for endoscopic treatment of fistulas in the digestive tract

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.

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Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Kirschniak A, Kratt T, Stüker D. et al. A new endoscopic over-the-scope clip system for treatment of lesions and bleeding in the GI tract: first clinical experiences. Gastrointest Endosc 2007; 66: 162-167
• 2 Von Renteln D, Vassiliou MC, Rothstein R. et al. Randomized controlled trial comparing endoscopic clips and over-the-scope clips for closure of natural orifice transluminal endoscopic surgery gastrotomies. Endoscopy 2009; 41: 1056-1061
• 3 Haito-Chavez Y, Law JK, Kratt T. et al. International multicenter experience with an over-the-scope clipping device for endoscopic management of GI defects (with video). Gastrointest Endosc 2014; 80: 610-622
• 4 Gaj F, Andreuccetti J, Trecca A. et al. Identification of internal fistolous orifice: evolution of methylene blue technique with a mini-probe. Clin Ter 2012; 163: 57-60

Publication History

Article published online:
27 March 2020