Endoscopy 2019; 51(04): S88
DOI: 10.1055/s-0039-1681430
ESGE Days 2019 oral presentations
Friday, April 5, 2019 17:00 – 18:30: Video lower GI 2 South Hall 1A
Georg Thieme Verlag KG Stuttgart · New York

SUCCESSFUL CLOSURE OF A RECTAL FISTULA OF CROHN'S DISEASE USING ENDOSCOPIC SUBMUCOSAL DISSECTION OF THE FISTULOUS TRACT COMBINED WITH AN OVER THE SCOPE CLIP

Autor*innen

  • T Wallenhorst

    1   Department of Endoscopy and Gastroenterology, CHU Rennes, Rennes, France

  • M Pioche

    2   Department of Endoscopy and Gastroenterology, Pavillon L, Edouard Herriot Hospital, Lyon, France

  • J Jacques

    3   Department of Endoscopy and Gastroenterology, Dupuytren Hospital, Limoges, France
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Publikationsverlauf

Publikationsdatum:
18. März 2019 (online)

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Aims:

Luminal fistulas of Crohn's disease represent a therapeutic challenge, with frequent use of surgery despite the advent of biologics. There is no reported case of effective endoscopic treatment in the literature. Submucosal dissection of the fistulous orifice combined with clip closure has been described as effective for two cases of chronic oeso-tracheal fistulas and one case of fistula on rectal anastomosis. We report the first success of this technique, to treat a refractory rectal fistula of Crohn's disease.

Methods:

A 35-year-old woman was referred for Crohn's disease with ileal fistula, pre-sacral and left gluteal abcess and sacral osteitis. Initial management consisted of ileocecal resection with ileostomy, prolonged antibiotic therapy and percutaneous radiological drainage. After 4 months, colonoscopy showed a rectal fistulous orifice. MRI showed a 25 mm long fistulous tract, responsible for the persistence of pre-sacral infiltration. The rectal mucosa was otherwise non-inflammatory. Stoma reversal was contraindicated with little surgical solution because of the location of the fistula.

We performed endoscopic submucosal dissection (ESD) of a mucosal patch surrounding the fistulous orifice (10 mm in diameter), using Hybrid Knife T (ERBE, Germany). To allow deep dissection of the entire fistulous tract we used a clip + line system. The exposed area was closed using an over-the-scope clip (OTSC) system (Ovesco, Germany). The ciprofloxacin – metronidazole antibiotic treatment was continued for 21 days.

Results:

The CT scan with rectal opacification 2 months later showed a complete regression of the collection and the absence of residual fistula tract allowing stoma reversal. The last clinical follow-up after 6 months confirmed complete resolution of rectal fistula.

Conclusions:

ESD of the fistulous tract associated with OTSC system closure seems effective for small chronic fistulas and could possibly also be used in fistulizing Crohn's disease. Prospective studies are needed to confirme this strategy.