Endoscopic seton placement for perianal fistula is usually done for simple, single,
short, and superficial fistula.[1]
[2] However, endoscopic seton placement for complex perianal fistula in fistulizing
Crohn's disease (CD) has not been described earlier.[3]
A 19-year-old lady came with complex perianal fistulae ([Fig. 1]; F-fistula external openings) with a history of chronic diarrhea and feculent fistula
discharge. Magnetic resonance imaging (MRI) pelvis confirmed with finding of complex
perianal fistulae (intersphincteric on both sides and with presacral extension; [Video 1], [Fig. 1B] and [C], axial and sagittal section of MRI, respectively). Colonoscopic biopsy confirmed
CD.
Fig. 1 (A) Complex perianal fistula with feculent discharge, (B) axial magnetic resonance imaging (MRI) showing right intersphincteric fistula (F)
draining into rectum (R), (C) MRI sagittal section showing presacral extension of fistula tract. (D) Jagwire (Boston Scientific) introduced into rectum through external opening of left-sided
fistula seen on colonoscopy, (E) guidewire (G) placed inside fistula cavity through large external openings of right-sided
fistula (F) using ultra-thin endoscope. F. Postprocedure after complete placement of all setons
across fistula tract.
First guidewire with hydrophilic tip (Jagwire, Boston Scientific, Massachusetts, USA)
was introduced through external opening of left-sided fistula (5 o'clock) and then
colonoscope was passed through rectum ([Fig. 1D]) and the tip of the guidewire was brought out. Draining seton was railroaded over
the guidewire and first seton was placed. For other fistulae, the guidewire passed
through external opening could not be retrieved through internal opening due to large
fistula cavity. Hence, an ultra-thin endoscope was introduced through large external
openings of right-sided fistulae (8 and 10 o'clock) and the guidewire was placed inside
the fistula cavity ([Fig. 1E], [Video 1]). Then endoscope introduced through rectum was negotiated into fistula cavity through
internal openings near anal verge by gradual withdrawal of scope near anal canal and
guidewire pulled out. Other setons were then railroaded over the guidewire to place
the setons as described for the first seton.[Video 1] Thus, all the fistulas could be drained using endoscopic seton placement (total
3) as a day care procedure without the need for surgery ([Fig. 1F], [Video 1]). The entire procedure was done under conscious sedation (propofol and ketamine)
without fluoroscopy or contrast injection to locate internal opening. Patient was
given intravenous (3 days) followed by oral antibiotics (2 weeks) (ciprofloxacin and
metronidazole) following which infliximab was initiated (3 weeks from index procedure).
The patient responded clinically with reduction in fistula discharge and is being
currently followed up.
In conclusion, endoscopic seton placement in complex perianal fistula is feasible
using ultra-thin endoscope in day care settings. Large internal opening allowed introduction
of ultra-thin endoscope in this case. This could be particularly helpful in minimizing
surgical morbidity and hospital stay and initiation of biologics without delay in
perianal fistulizing CD.
Video 1 Endoscopic setons placement for complex perianal fistula for complex perianal
fistulizing Crohn's disease.
