Rectovaginal fistulas (RVFs) are abnormal communications between the
anterior wall of the rectum and the posterior vaginal wall. The incidence of
RVFs is relatively low; most of them are related to obstetric injury
[1]. Patients complain of uncontrollable passage of gas
or feces from the vagina. RVFs may be managed both medically and surgically.
Endoscopic approaches with endoclip closure of gastrointestinal fistula and
injection of tissue adhesive have been proposed [2], but
a combined approach using both methods has not been described. We present a
case of a RVF successfully treated endoscopically with N-2-butyl-cyanoacrylate (Histoacryl; B. Braun, Melsungen,
Germany) and Resolution clips (Microvasive Endoscopy, Boston Scientific Corp.,
Natick, Massachusetts, USA).
A 78-year-old woman with a diagnosis of acute myeloid leukemia
complained of passing stool and gas from the vagina. Having rejected surgery,
she was referred to our unit, where sigmoidoscopy showed a 6-mm orifice in the
anterior wall of the rectum ([Fig. 1]).
Fig. 1 A 6-mm orifice in the
anterior wall of the rectum.
Three Resolution clips were placed in order to appose the margins
([Fig. 2]), and a 1 : 1 mixture
(2 ml) of Histoacryl and lipiodol was injected into the internal opening
and fistulous tract ([Figs. 3] and
[4]).
Fig. 2 Three Resolution clips
placed in order to appose the margins of the orifice.
Fig. 3 A 1 : 1
(2 ml) mixture of Histoacryl and lipiodol was injected into the internal
opening and fistulous tract.
Fig. 4 Appearance after
injection.
The patient had early relief of her complaints and remained
asymptomatic 2 months after the procedure.
Cyanoacrylates are a class of synthetic glues that rapidly solidify
upon contact with body fluids. Histoacryl is the most commonly used
cyanoacrylate glue for gastrointestinal applications. It has shown to be
successful in the closure of pancreatic [3] , biliary
[4], and gastrointestinal fistulas [5] in patients in whom conservative treatment has failed as
well as in surgically high-risk patients. Mixing Histoacryl with lipiodol
retards polymerization.
In our experience, a combined approach using Resolution clips and
Histoacryl may improve the rate of technical success in the endoscopic
treatment of RVFs, since clips not only work in apposing the margins, but act
as a scaffold for the glue.
Endoscopy_UCTN_Code_TTT_1AQ_2AG
