Hello, I'm Faisal from Henry, a third-year fellow going into fourth year at Henry Ford. So our case is a novel approach to endoscopy, to anterior cutaneous fistula closure. So we have, these are disclosures. So as a background, anterior cutaneous fistulas occur when there's abnormal tract between the skin and the small intestine. Several factors can contribute to forming the fistula, including malignancy, inflammatory bowel diseases, as well as post-surgical complications. Management usually was surgical. There's a recent paradigm shift for endoscopic closures, which include endoscopic suturing, vacuum device therapy, over-the-scope clips, and novel approach for off-label use of various devices, which we have used one of them. So our case is a 61-year-old lady with a history of metastatic colon cancer, status post-sigmoid resection with loop ileostomy, and palliative chemotherapy. Her course was unfortunately complicated by symptomatic anterior cutaneous fistula, and she was deemed to be a poor surgical candidate. The surgery attempted multiple glue injections and failed. So we've done a fistulogram confirming the fistula. And we attempted ileoscopy for trying to reach the fistula. Despite a guide wire in the fistula, we failed to reach it, discussed with patient and surgery what to do next. And they said, let's try again to do a small bowel enteroscopy with attempted closure. And if that fails, then we might do a cardiac septal occluder device. So endoscopic closure attempted, small bowel enteroscopy was normal. We failed again to reach out the anterior cutaneous fistula side, despite having a guide wire in. This is the small bowel enteroscopy with a fluoroscopic view. And then we can see the wire here, guide wire from the fistula tract, but unfortunately failed to reach, despite being very close. So we were going to use the septal occluder device. So it's a double-disc, self-expandable wire mesh. As you see, it's connected by a connecting waist. And it comes in various sizes, from 4 to 38 millimeter. It has activated Dacron patches that activate prothrombotic and proendothelialization materials. So we set up by threading the septal occluder device into a delivery system and then through a catheter, which is what we used as a 5-4-3 biliary catheter. We went through the fistula, injected a contrast, confirmed the fistula's tract into the small intestine, then it was deployed under fluoroscopy. And then injected contrast after as well, which yielded no more filling of the small bowel. After that, we injected blood to have the activation of proendothelialization and prothrombotic material from the inside. On follow-up, on two days, one month and three months follow-up, the patient continued to do well, and she said there was no drainage. So this is a case report for highlights of successful off-label use of a septal occluder device. It's unique that it was done under fluoroscopy guidance after failed endoscopic approach, and it also underscores the importance of multidisciplinary approach, discussion with the patient, and use innovative solutions when we don't have, with challenging clinical scenarios and we don't have a lot of options. That's it. Questions? I was wondering, what happened to the, like, the material in that septal occluder plate? On the follow-up, did it go in, or did it just get buried in the skin? So it's a double-disk. You think about it as a LAMPS. Basically there's two flanges that are keeping the tract closed from both sides, so it stayed in place without any leakage and continued to be in place. And of course it's a metastatic cancer, so it's a palliative approach, but there was no reported complications from the procedure.

anterior cutaneous fistula

endoscopy

cardiac septal occluder

fluoroscopic guidance

multidisciplinary approach