Caio Almeida Perez

A 56-year-old man underwent rectosigmoidectomy, partial cystectomy, and derivative colostomy for locally advanced distal rectal adenocarcinoma, persistent after chemoradiation. On the 25th postoperative day, he presented clinical worsening and increased abdominal drain output, and was submitted to tomography with intravesical contrast infusion, which showed a rectovesical fistula communicating with the surgical drain ([Fig. 1]). Rectoscopy showed a semi-circumferential leak of the colorectal anastomosis. Endoscopic exploration of the pelvic cavity allowed removal of clots and necrosis, and cleansing with 3 % hydrogen peroxide was done. While the surgical drain was in place, tube-in-tube endoscopic vacuum therapy in the intracavitary position was performed. A guidewire was inserted through the pelvic drain and captured with a grasper. The guidewire was then used to introduce a 14-Fr Levine tube into the surgical drain. Continuous aspiration with 125 mmHg negative pressure was started ([Video 1]). The pump was disconnected daily so tubes could be used to irrigate the cavity [1] [2] [3]. Video 1 Tube-in-tube endoscopic vacuum therapy method (TT-EVT). After 10 days, a new rectoscopy showed significant reduction of leakage and the pelvic cavity, with granulation tissue formation. A full-thickness endoscopic clip was deployed, achieving complete closure of the colorectal anastomotic fistula ([Fig. 2]). The decision was to maintain the intracavitary tube-in-tube endoscopic vacuum therapy to drain the urinary fistula. After another 10 days, a third rectoscopy showed sustained closure of the anastomotic fistula. An ultra-slim endoscope (4.9 mm) was inserted through the drain path, which was thin and long, mimicking a remaining “cystostomy.” Negative pressure was turned off and a Penrose drain was left near the vesical wall. Repeat tomography with intravesical contrast infusion 25 days later showed a well-positioned clip without extravasation of contrast. The pelvic drain was removed and the patient discharged. Control rectoscopy confirmed a defective closure and allowed reconstructive surgery. Tube-in-tube endoscopic vacuum therapy can be done through previously placed surgical drains into the intracavitary position. It is an effective, easy-to-assemble, and low-cost treatment option even for complex digestive fistulas. Endoscopy_UCTN_Code_TTT_1AQ_2AG Publication Date: 15 November 2021 (online) © 2021. Thieme. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

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