This video describes a 73-year-old male with past medical history, including a TIA in 2012 and mild asthma. In September 2019, he presented to the emergency department with abdominal pain, and a CT scan found a 3.1 by 4.5 by 2.2 cm cecal mass. The underwent a colonoscopy and was found to have cecal cancer. The CT scan at the time of diagnosis also found a 4.1 by 3.0 by 3.5 cm enhancing exophytic anterior renal mass in the right upper pole of the kidney. A staging CT scan of the chest revealed no metastases. In October 2019, he had a combined right hemicolectomy with side-to-side ileocolonic anastomosis and right partial nephrectomy. His pathology confirmed that he had a PT4A-PN0 colon adenocarcinoma and a concurrent right PT3A-PNX chromophobe renal cell carcinoma. Margins of his CRC were negative, and all 20 sampled lymph nodes were also negative. Unfortunately, postoperatively, he developed devascularization of the residual right kidney with hematoma formation. He then developed an abscess, which was managed initially with percutaneous drains and broad spectrum antibiotics. He eventually required a laparotomy in December 2019 for washout and drainage of the persistent perinephric abscess. In February 2020, he represented with abdominal pain and purulent drainage from his pigtail catheter. Despite optimal antimicrobials and excellent drain care, his collection persisted. His tube check showed contrast going into the bowel. A colonoscopy done in February revealed no evidence of recurrence of the ileocolonic anastomosis. Shown here is a 1 cm hole in the blind limit of the anastomosis. The external drain placed by IR transverses this hole with the pigtail in the colon. A second colonoscopy done the next day was performed to exchange his pigtail for a Foley catheter. In this procedure, a wire is inserted through the pigtail and secured in the colon. The pigtail catheter is removed, and here is the 14 French Foley catheter inserted in the colon. The balloon is inflated to 10 mL and traction is placed to try and close the cavity between the tract and the skin. Despite continued antibiotics, the collection did not completely collapse. A third colonoscopy was attempted with the assistance of percutaneous endoscopy. Here we show the insertion of a wire through the Foley catheter. The Foley catheter was then removed. This was secured in the colon with biopsy forceps. A cholangioscope was inserted in the cavity tract. The cavity was inspected with no evidence of residual cancer. As seen in the images of the cavity, no pus was seen. The official tract shown here was the width of the 14 French Foley catheter. Seen here is the cholangioscope inside the colon viewed from the pediatric colonoscope. Tension was created with the biopsy forceps. The blind limb of the anastomosis is seen well here with the orifice of the tract. Bicap cautery was used to cauterize the orifice of the fistula tract and the blind limb of the ileoclonic anastomosis. The final result is shown here. A 14 French percutaneous balloon gastrosomy tube is shown here inserted into the colon. The balloon was inflated and traction was created with the bolster at the skin. Unfortunately he had persistent drainage from the fistula site and a CT scan showed only partial collapse of the cavity. Another colonoscopy was performed with placement of an endoloop fixed in place by hemostatic clips. Another colonoscopy was performed using the dual channel gastroscope. The fistula was seen here behind the endoloop. The endoloop was fixed in place by hemostatic clips, here with two clips. Further clips were added to create the endoscopic cerclage. Further clip deployment. The dual channel gastroscope allowed the placement of the endoloop around the fistula orifice. Clips were systematically placed. In total 13 clips were deployed. Shown here is the deployment of the endoloop with formation of the cerclage. No error was noted passing through the defect of the enterocutaneous fistula at the end of the procedure. On a follow up colonoscopy one month later the fistula tract was significantly smaller. The previous endoloop and clips had fallen off. The fistula was treated with APC and 5 endoclips which were used to close the fistula tract. Clinically the patient has no further drainage from the previous fistula site. He's off antibiotics and has no drains in place. This video highlights the different ways in which postoperative fistulas can be managed. Postoperative collections are common and often collapse with percutaneous drainage. Percutaneous endoscopy is an option to direct non-operative management of persistent collections. A colocutaneous fistula closure can be performed by endoscopic cerclage using an endoloop.

cecal cancer

renal cell carcinoma

surgeries

complications

postoperative fistulas