Case Presentation A 71-year-old man underwent a rectosigmoidectomy for adenocarcinoma of the upper
rectum with primary anastomosis 4 cm from the anal verge, protective ileostomy, and
prophylactic cavity drainage. On the 5th postoperative day, he developed a semicircular
anastomotic dehiscence without signs of peritonitis or sepsis. Conservative treatment
was chosen with antibiotics and maintenance of the cavity drain, which was well-positioned
and draining purulent fluid. Clinical improvement allowed discharge on the 14th postoperative
day, with the cavity drain still in place. Two months later, a follow-up colonoscopy
revealed a patent anastomosis with a 1-cm fistulous opening communicating with a 3-cm
cavity, through which the tubulolaminar drain was visible. Extraluminal vacuum therapy
with an 18Fr endosponge was applied, later replaced by a double-tube system. After
two weeks and three exchanges, the fistulous opening and tract were obliterated. Two
weeks later, the ileostomy was closed with good postoperative recovery and discharge
on the 3rd day. The patient subsequently presented with regular bowel movements and
good continence.
Discussion Anastomotic fistula is the main complication of colorectal surgeries, occurring in
up to 15-20% of cases, and is associated with significant morbidity. In stable patients
with extraperitoneal anastomoses, particularly those with a pre-existing diversion
stoma, minimally invasive treatments aimed at preserving the anastomosis are highly
desirable. Endoscopic therapies, including stents, fibrin glue, clips, double pigtail
catheter drainage, and, more recently, vacuum therapy, are noteworthy. Vacuum therapy
works by removing fluids, reducing edema and bacterial load, increasing blood flow,
and stimulating granulation tissue. The average treatment duration ranges from 35
to 60 days, requiring multiple dressing changes, which can be made with sponges or
a double-tube structure, with or without substance instillation. Early intervention
is associated with better outcomes.
Conclusion Early consideration of endoscopic vacuum therapy can increase the resolution rates
of colorectal fistulas with shorter treatment durations, reducing reoperation rates
and permanent stomas. However, high costs, prolonged treatment times, and the availability
of trained professionals remain limiting factors in the widespread use of this technique.
