Hello, my name is Ruma Patel and I am the current gastroenterology fellow. Today we will be discussing a not-so-okay pouch, an endoscopic closure of an enterobasical fistula. The endoscopic approach was multipronged to ensure recurrence of the fistula did not occur. The steps involved first localization of the fistula tract, de-epithelialization of the existing tract with a brush, cauterization of the mature tract with a gold probe, denudation of the opening with APC, and endoscopic suturing to close the fistula. The case we will be discussing today is involving a 76-year-old female with an extensive history that began in 2002 with a total practicalectomy and formation of a K-pouch. Since then, she's had multiple abdominal surgeries for recurrent obstructions and bladder injuries. Most recently, she developed an enterobasical fistula that underwent repair in 2023. She's admitted again because of concerns of recurrence of the same fistula. As you can see, the patient has undergone quite a few surgeries, but the biggest ones to highlight are the formation of the K-pouch in 2002 and the most recent repair of the enterobasical fistula in 2023. Upon reviewing the imaging, we were able to see the connection of the fistula from the K-pouch to the bladder wall. Endoscopically, anatomy was confirmed with the afferent limb and an investigation of a possible fistula tract opening was able to be performed. Methylene blue and saline were injected through a bladder foley and used to confirm the opening of the fistula. Once the opening was confirmed, a guide wire was introduced with a brush to de-epithelialize the tract. Once the direction of the tract could be better appreciated, a guide wire was removed and the brush was used by itself to de-epithelialize the fistula tract. This is a very important step in helping to promote closure of the fistula. The mature tract was cauterized using a gold probe to help promote closure again within the tract. With the multi-pronged approach that we discussed today, it was important to both manage the inside of the tract as well as the opening of the tract as we will now do in the next few steps. Argon plasma coagulation was used in a circumferential manner around the fissula tract opening. This was done to promote additional healing and closure of the tract opening. Endoscopic suturing can be used to help ensure the opening is closed. A figure of 8 stitch was used in this case to close the fistula opening. Suturing allows for deeper mucosal bites and keeps the tract from opening again. In this case, a total of 4 bites were taken to create the figure of 8 stitch. After the fourth and final bite, the stitch was buried, and the suturing device was removed. The final endoscopic view showed no visible opening of the fistula, and a fistulogram in the next few days confirmed continued resolution. In conclusion, endoscopic closure of fistulas is possible, but there is currently no gold standard. As seen in this case, a multi-pronged method can be used to target these lesions, and is very effective in keeping fistulas closed. Endoscopic closure of fistulas can become a first-line treatment option, especially in patients that are not ideal surgical candidates. Thank you for listening, and I hope you have a great day.

endoscopic closure

enterobasical fistula

gastroenterology

cauterization

endoscopic suturing