Plugging the stent. A novel approach to manage ileocolorectal fistula by plugging a viable stent with a sinoacrolate-filled AVP2 plug. Anastomotic leak is a critical complication after rectal surgery, with reported incidence of 5-20% of cases. The management options for persistent anastomotic leaks and fistulae include surgical resection of the leaking anastomotic or fistula site or the creation of a permanent end stoma. We present a novel approach to manage an ileocolorectal fistula following low anterior resection utilizing a viable stent and a plug created by a sinoacrolate-filled AVP2 plug. We present the case of a 44-year-old status post chemotherapy, radiation, and low anterior resection with a temporary ileostomy for a locally advanced rectal cancer who was referred to our center for a second opinion regarding a permanent colostomy due to a chronic refractory anastomotic breakdown. On colonoscopy, a patent end-to-side colorectal anastomosis was noted, characterized by a disrupted staple line communicating with a 2 cm presacral abscess. The presacral abscess communicated approximately with a 7 mm distal ileum fistula. This ileocolorectal fistula was causing pelvic pain due to bile salt-induced perineal excoriation. The abscess was cleaned and a 10x10 viable stent was deployed between the ileum and the rectum to bypass the abscess. The lumen of the stent was then plugged with a sinoacrolate-filled AVP2 plug 16x12 mm under fluoroscopic guidance. The viable stent over the disrupted colorectal staple line prevents communication with the pre-sacral abscess. The plug functions as a water seal and prevents drainage of excoriating small bowel contents, including enzymes, into the pre-sacral cavity and decreasing perennial excoriation. This is the conceptual diagram illustrating the principle behind the intervention. As visualized here, the viable stent was deployed between the ileum and the rectum and bypassed the sacral abscess cavity. The subsequent placement of the AVP2 plug in the lumen of the stent functioned as a water seal, stopping leakage of the small bowel contents into the cavity and thus reduced the perennial excoriation. This is the fluoroscopic image showing the viable stent and a plug created by the sinoacrylate-filled AVP2 plug and the absence of contrast leak at the fistula site. At the three-month follow-up, the patient is doing well and the symptoms have resolved. A follow-up CT scan is scheduled for six months after the procedure. We describe the successful endoscopic management of an ileocolorectal fistula, communicating with the presacral abscess using a viable stent and a sinoacrylate-filled AVP2 plug.

ileocolorectal fistulas

viable stent

sinoacrylate-filled plug

rectal cancer complications

presacral abscess