Endoscopic closure of a rectovaginal fistula combiningN-2-butyl-cyanoacrylate (Histoacryl) and Resolution clips

Abstract

Rectovaginal fistulas (RVFs) are abnormal communications between the anterior wall of the rectum and the posterior vaginal wall. The incidence of RVFs is relatively low; most of them are related to obstetric injury [1]. Patients complain of uncontrollable passage of gas or feces from the vagina. RVFs may be managed both medically and surgically. Endoscopic approaches with endoclip closure of gastrointestinal fistula and injection of tissue adhesive have been proposed [2], but a combined approach using both methods has not been described. We present a case of a RVF successfully treated endoscopically with N-2-butyl-cyanoacrylate (Histoacryl; B. Braun, Melsungen, Germany) and Resolution clips (Microvasive Endoscopy, Boston Scientific Corp., Natick, Massachusetts, USA). A 78-year-old woman with a diagnosis of acute myeloid leukemia complained of passing stool and gas from the vagina. Having rejected surgery, she was referred to our unit, where sigmoidoscopy showed a 6-mm orifice in the anterior wall of the rectum (• " Fig. 1). Three Resolution clips were placed in order to appose the margins (• " Fig. 2), and a 1 : 1 mixture (2 ml) of Histoacryl and lipiodol was injected into the internal opening and fistulous tract (• " Figs. 3 and 4). The patient had early relief of her complaints and remained asymptomatic 2 months after the procedure. Cyanoacrylates are a class of synthetic glues that rapidly solidify upon contact with body fluids. Histoacryl is the most commonly used cyanoacrylate glue for gastrointestinal applications. It has shown to be successful in the closure of pancreatic [3] , biliary [4], and gastrointestinal fistulas [5] in patients in whom conservative treatment has failed as well as in surgically high-risk patients. Mixing Histoacryl with lipiodol retards polymerization. In our experience, a combined approach using Resolution clips and Histoacryl may improve the rate of technical success in the endoscopic treatment of RVFs, since clips not only work in apposing the margins, but act as a scaffold for the glue.

Minimally invasive endoscopic repair of rectovaginal fistula

“…Endoscopic clipping: Endoscopic clipping is another technology using endoclips to completely close gastrointestinal leaks and fistulas, initially applied for iatrogenic gastric perforation in 1993[ 44 ]. John et al [ 45 ] reported the first successful closure of an RVF with TTSCs, which was also applied for repair of refractory RVF[ 33 ]; Ortiz-Moyano et al [ 46 ] described a combined approach using TTSCs and tissue adhesive that improved the rate of technical success in the endoscopic clips treatment of RVFs, since clips not only worked in opposing the margins, but acted as a scaffold for the glue. OTSCs for the gastrointestinal tract had greater force and a consistently high mean rate of procedural success of 80%-100%, and a durable clinical success rate of 57%-100%, and was preferred over TTSCs for closure of gastrointestinal fistulas[ 47 ].…”

Case report: Treatment of rectovaginal fistula with Bioglue®

“…3,4 There have also been a few case reports of the use of fibrin or bioglue for the repair of RVFs, but only in a few select patients has it been successful. 5,6 One case reported the use of histoacryl as a sealant placed between endoclips after a 78-year-old female refused surgery and at follow-up was asymptomatic at 2 months. 5 Abel et al had the largest case report series with ten patients treated with a fibrin glue for a mixture of complex RVFs with 60% of patients having complete healing of the fistula.…”

“…5,6 One case reported the use of histoacryl as a sealant placed between endoclips after a 78-year-old female refused surgery and at follow-up was asymptomatic at 2 months. 5 Abel et al had the largest case report series with ten patients treated with a fibrin glue for a mixture of complex RVFs with 60% of patients having complete healing of the fistula. 6 The reported failures were due to immuno-compromised states due to Crohn's disease and HIV, but the patients still reported decreased drainage.…”

“…Agent Follow-up Outcome/# of cases Abel et al 6 Fibrin glue 3-12 months 4 of 5 healed fistula (80%) Ortiz-Mayano et al 5 (Histoacryl) and resolution clips 2 months Resolution of fistula One case Alexander et al 7 Bioglue Not reported Failed One case De la Portillia et al 8 Bioglue 3-21 months Cure rate in 7 patients (50%) De la Portillia et al 9 Bioglue 60 months New cure rate in original 7 patients only 3 patients remained asymptomatic (21%) group underwent transanal advancement flap repair with bioglue and the RVF patient had bioglue alone. Of the eight patients only one patient had complete resolution of the fistula tract with the others suffering complications of pain, abscess, and persistent fistula tract.…”

Incidence and Treatment Outcomes of Rectovaginal Fistula After Rectal Cancer Resection

“…The overall experience with clips is limited to case reports alone that have shown success. 15,16 Endorectal and transvaginal advancement flaps are among the more popular techniques for RVF repair because of their familiarity by the surgical team and high procedure acceptance by patients. The average closure rates with these repairs are 60%.…”