My name is Sunil Gupta, and on behalf of my co-authors, I would like to present our video entitled Retrograde EUS-Guided Endoenterostomy Using a Lumen-Opposing Metal Stent for the Management of a High-Output Endocutaneous Fistula and Ileostricture in a Complex Surgical Abdomen. A 26-year-old male sustained significant traumatic thoracohabdominal injuries following a gunshot. He underwent several laparotomies, small bowel resections, a partial hepatectomy, and an extended left hemicolectomy with an end colostomy formation. An abdominal flap was required to close the abdomen. The patient subsequently developed a high-output endocutaneous fistula and loss of colostomy output. CT imaging confirmed an endocutaneous fistula from the ileum to the anterior abdominal wall, as well as a severe ileostricture that was distal to the fistula. In the context of his complex surgical abdomen and proximity of the endocutaneous fistula to the abdominal flap, surgical re-intervention was deemed to be high-risk. He was thus referred for endoscopic management. A pediatric colonoscope was inserted through the colostomy and advanced via the colon and ileocecal valve into the ileum. Under fluoroscopic guidance, we injected a combination of methylene blue and contrast dye from the skin side of the endocutaneous fistula, as marked on the fluoroscopic image with an artery forceps. A dilated segment of small bowel was filled with no downstream passage of contrast. In the fluoroscopic image, the presence of a bullet can also be identified. Approximately 90 cm from the ileocecal valve, we encountered a benign enteric stenosis that could not be traversed. Contrast was injected, with fluoroscopy revealing a 10 cm long tortuous stenosis that extended to the previously filled loop of small bowel. Given the length, character and position of the stricture, endoscopic balloon dilation and enteral stenting were technically infeasible. We proceeded to retrograde EUS-guided enteroenterostomy formation. With the aid of a guide wire, and under endoscopic, fluoroscopic and endosonographic guidance, a linear echoendoscope was advanced into the ileum via the colostomy, cecum and ileocecal valve. Approximately 50 cm from the ileocecal valve, we identified an adjacent dilated loop of small bowel. Water was instilled through the endocutaneous fistula, with the endosonographic view demonstrating filling. A 19 gauge needle was then punctured through, with subsequent aspiration confirming the presence of methylene blue. Water was instilled to expand the area. We then created an EUS-guided enteroenterostomy using a 15 mm luminoposing metal stent. Passage of methylene blue and contrast dye through the stent confirmed accurate deployment, with proximal small bowel able to be visualized endoscopically. The patient's colostomy output returned and the intracutaneous fistula output diminished. This facilitated healing of his abdominal free flap. Repeated endoscopic and fluoroscopic assessment confirmed complete expansion of the metal stent. Electrocautery-enhanced luminal position with metal stenting is well established. It can facilitate the formation of an anchored anastomosis across non-adherent luminal structures in a single-step fashion. Through this case, we have reported a novel application of this technique in the management of a complex post-surgical trauma patient with a high-output intracutaneous fistula and a deep enteric stenosis.

abdominal injuries

gunshot wound

colostomy

endocutaneous fistula

ileostricture