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Transvaginal view of fistula.
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Figure 2: Transvaginal view of fistula.

Mentions: The procedure was performed in the endoscopy suite under both endoscopic and fluoroscopic guidance. The patient was placed in the left lateral decubitus position. The preprocedural barium enema was reviewed to assess the location of the fistula, the length and diameter of the stricture, and the anatomic course of the colon including angulation and redundancy (Figure 1). The endoscopic examination was initiated with the adult flexible sigmoidoscope, and an adult upper gastroscope was used later during the procedure. Once intravenous sedation was adequate, the vagina was intubated and the endoscope was advanced to its apex, the usual location of the fistula (Figure 2). The fistulous opening in the vagina was identified and cannulated with a flexible guidewire (Hydra Jagwire, Boston Scientific, Natick, Maryland). A biliary and angiographic catheter were also used to provide the soft wire with more support, and in patient 2, a stiffer wire (Amplatz Super Stiff, Boston Scientific, Natick, Maryland) was used to traverse the fibrotic, radiated pelvis. Once the vaginal wire crossed the fistula, it was advanced into the colonic lumen proximal to the area of the stricture and fistula (Figure 3A). The endoscope was withdrawn out of the vagina keeping the vaginal wire in place, and it was reinserted transanally and advanced to the area of the stricture (Figure 3B). Reaching the stricture and fistula was difficult, and this portion of the procedure was challenging in patient 2 due to the angulation and redundancy of colon and rigidity of the pelvis. The upper gastroscope was used with a glidewire (Boston Scientific, Natick, Maryland) to traverse the colonic stricture in patient 2 and then exchanged for the Amplatz Super Stiff through an angiographic catheter. In both patients, the colonic wire was advanced across the stricture and fistula under fluoroscopic guidance. The intersection (“kissing”) of both colonic and vaginal wires pinpointed the exact location of the colovaginal fistula (Figure 3C). The endoscope was withdrawn with both wires in place. The delivery device of a 16 French covered Ultraflex stent (12 cm long, 18 mm x 23 mm diameter) (Boston Scientific Corporation, Natick, Maryland) was advanced over the colonic wire under fluoroscopic and endoscopic guidance after reintroducing the endoscope transanally (Figure 4). The stent length was enough to provide at least 2 cm of coverage proximal and distal to the stricture. In patient 1, the stent was centered over the fistula before deployment, and the position was confirmed by verifying the radiopaque markers of the delivery device. The vaginal wire was then withdrawn, and the stent was deployed under both endoscopic and fluoroscopic guidance while the delivery device was held steady to avoid malpositioning. The delivery device and colonic wire were then retrieved, and the stented lumen was visualized endoscopically (Figure 5). Although we were able to traverse and pinpoint the exact location of the fistula in patient 2, we were unable to advance the stent delivery device past the stricture. The rigidity of the patient's previously operated and radiated pelvis would not allow the softer delivery device to advance into the colon proximal to the stricture. Because we could not fully span the stricture with a proximal margin of normal colon, we elected not to deploy the stent to avoid the high risk of migration.

Endoscopic Stenting of Colovaginal Fistula: the Transanal and Transvaginal “Kissing” Wire Technique

Abbas MA, Falls GN - JSLS (2008 Jan-Mar)

Bottom Line: Interventional endoscopy is a rapidly evolving field allowing surgeons and endoscopists to approach surgical conditions nonoperatively.Stenting of benign colorectal disease has been limited due to technical issues and lack of long-term data.Colovaginal fistula can be a challenging condition to treat.

Affiliation: Department of Surgery, Section of Colon and Rectal Surgery, Kaiser Permanente, Los Angeles, California 90027, USA.

Interventional endoscopy is a rapidly evolving field allowing surgeons and endoscopists to approach surgical conditions nonoperatively. Stenting of benign colorectal disease has been limited due to technical issues and lack of long-term data. Colovaginal fistula can be a challenging condition to treat. In this report, we describe the technical aspect and results of endoscopic stenting of benign colovaginal fistula in 2 patients, using the combined transanal and transvaginal approach.

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