This ASG video tip is sponsored by Braintree, maker of the newly approved Soufflave and Soutab. Plug and Play, the management of a refractory collocutaneous fissula. Collocutaneous fissulae can develop because of many medical conditions, including bowel surgery, inflammatory bowel disease, and malignancy. Chronic fissulae management can be complex. It can also be difficult to treat non-operatively. Endoscopic therapy currently involves covered and tear extent placement, endoscopic suturing, and endoscopic clipping, all of which have variable success rates. Vascular plugs are occlusion devices traditionally used to close peripheral vascular defects. Endoscopic delivery of these devices is a novel approach to treat a variety of gastrointestinal conditions, including enterocutaneous fissulae. In the following case, we demonstrate our experience delivering a vascular plug endoscopically to treat a chronic collocutaneous fissula that did not respond to conservative measures or traditional endoscopic therapies. A 62-year-old gentleman presented with sigmoid diverticular perforation requiring a proctosigmoidectomy and endcolostomy. Ten months later, he underwent reversal of the colostomy. His post-reversal course was complicated by persistent anastomotic stricture and a collocutaneous fissula. The fissula persisted despite central parenteral nutrition and bowel rest. He was therefore referred to gastroenterology for endoscopic evaluation and management. A sigmoidoscopy demonstrated a benign appearing stricture at the site of the anastomosis. This was suspected to be the site of the fissula. However, due to the degree of the stenosis, the fissula was unable to be explored. In order to confirm the position of the fissula, a 0.035 inch by 260 centimeter wire was introduced antegrade from the skin opening of the fissula tract and passed into the lumen under direct endoscopic visualization. The decision was then made to place a stent across the stenosis to dilate the stricture and cover the fissula. First, the wire placed antegrade from the skin was removed. Next, a guide wire was passed into the lumen of the colon traversing the stricture. A cold 20 millimeter by 10 millimeter lumen opposing metal stent was then deployed without electrocautery enhancement. Fluoroscopy performed after injection of contrast into the colonic lumen demonstrates appropriate positioning of the lumen opposing metal stent. No contrast is observed extravasating towards the skin. A repeat sigmoidoscopy was planned in one month. In the weeks following the procedure, the patient had dramatic improvement of drainage from his fissula. A sigmoidoscopy performed one month later demonstrated a patent lumen opposing metal stent. The stent was removed with rat tooth forceps. The underlying colonic lumen was noted to be widely patent, indicative of successful therapy of the anastomotic stricture. An upper endoscope was able to be advanced to the transverse colon without difficulty. Next, the fissula was assessed via fluoroscopy. Contrast was observed extending towards the patient's skin, suggestive of ongoing fissula. The decision was made to suture the fissula closed. First, APC therapy was delivered to help promote deepithelialization. The endoscope was removed and equipped with a suturing device. The device was loaded with 2.0 polypropylene suture. The fissula was then sutured closed with a single running suture with good tissue approximation. Post-therapy fluoroscopy demonstrated no persistent contrast extravasation after suturing. While the patient reported that the drainage had improved, he did notice staining on his clothes at the site of the fissula. It was unclear if this represented a sinus tract or persistent fissula and therefore another sigmoidoscopy was performed. A sigmoidoscopy demonstrated a persistent fissula in the sigmoid colon. An over-the-scope clip was considered. However, the fissula was sunken into the wall of the colon which would have made deployment technically difficult. The decision was made to deploy vascular plug occlusion therapy for refractory fissula. First, we will review endoscopic vascular plug therapy with an ex vivo demonstration. The vascular plug is attached to a wire which can be used to advance and retract the vascular plug as shown here. It is important to note that the prepackaged catheters are only 100 centimeters in length. Therefore, the vascular plug must be loaded onto a separate catheter to deliver occlusion therapy endoscopically. We favor the use of a biliary dilation catheter which we modify twice to accommodate the vascular plug. First, the tapered end of the biliary dilation catheter is cut. Next, the catheter is passed down the endoscope and then sized again to facilitate the delivery wire. The vascular plug is then fed through the working channel of the endoscope. The defect can then be engaged and the vascular plug can be deployed once satisfied with its positioning. The vascular plug is screwed onto the catheter and can be deployed with counterclockwise rotation as shown in this underwater demonstration. Now, returning to our patient, the fissula was cannulated with a 9 to 12 millimeter occlusion balloon over a 0.025 inch wire. The wire is seen extending towards the skin on fluoroscopy confirming the persistence of the collocutaneous fissula. The balloon was then removed and a 10 by 7 by 5 French biliary dilation catheter modified as previously discussed was then placed over the wire. After removal of the wire, a 6 millimeter by 6 millimeter vascular plug was placed in the fissula tract. A 6 millimeter vascular plug was chosen because the fissula was estimated to be 4 millimeters in diameter. In general, the vascular plug should be about 50% larger than the defect for adequate occlusion. Here, fluoroscopy demonstrates no opacification of the fissula's tract after vascular plug delivery. The correct positioning of the vascular plug was also confirmed endoscopically. A repeat sigmoidoscopy was performed 3 months after vascular plug therapy to surveil the fissula. This demonstrated endoscopic resolution of the collocutaneous fissula. Clinically, the patient has been followed for 7 months after vascular plug therapy. The patient notes no further drainage. In conclusion, chronic enterocutaneous fissulae can be difficult to treat. Endoscopic options, including endoscopic stenting and suturing, have variable rates of success. Further studies are needed to assess long-term outcomes for vascular plug therapy. However, endoscopic vascular plug therapy is a novel, promising option for non-operative fissula closure. Endoscopic vascular plug therapy is a novel, promising option for non-operative fissula closure.

endoscopic therapy

vascular plugs

chronic collocutaneous fissulae

case study

non-operative treatment