Endoscopic needle knife fistulotomy technique for ileal pouch-to-pouch fistula

A 19-year-old woman with refractory pan-ulcerative colitis, diagnosed in 2004, underwent a total proctocolectomy in 2006, followed by a two-stage ileoanal pull-through procedure. Severe pouchitis led to a two-stage J-pouch reconstruction in 2012. In June 2014, magnetic resonance enterography showed a pre-sacral abscess, which was drained percutaneously.

We performed a pouchoscopy with a GIF-H190 endoscope (Olympus, Tokyo, Japan) in an outpatient setting. After the administration of conscious sedation, inspection of the pouch showed a defect draining purulent material at the distal pouch along the anastomotic line ([Fig. 1]). Suspecting an anastomotic sinus or fistulous track, we used a 0.035-inch guidewire with a flexible tip (Boston Scientific, Natick, Massachusetts, USA) to investigate ([Fig. 2] and [Fig. 3]). A 3-cm-long pouch-to-pouch fistula was detected. A 1.8-mm needle knife (Boston Scientific) was used with electrocautery to cut across the fistulous track wall – now a septum separating the fistula from the pouch ([Video 1]). Three endoscopic hemoclips were placed along the opened fistula track to prevent re-formation of the fistula. Complete fistulotomy was achieved, and surgical intervention for abscess drainage was avoided. The procedure took 25 minutes and was uneventful.

Fig. 1 Purulent material draining from the fistula opening at the anastomotic line of the ileal pouch in a 19-year-old patient with a pre-sacral abscess.

Fig. 2 Insertion of the probe into the fistula opening.

Fig. 3 Use of the guidewire to investigate the fistula track.

Endoscopic use of the needle knife to open the pouch-to-pouch fistula.

Endoscopy_UCTN_Code_TTT_1AQ_2AF

 

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Competing interests: None