Surgical therapy with a diverting ileostomy for 2-3 months and subsequent recanalisation has been, up to now, the
therapy of choice for cancer patients with an anastomotic
rectovesical fistula. Although surgery allows for reliable
repair, it requires general anaesthesia and can be associated
with signif icant morbidit y and mor talit y as well as
prolonged stays in hospital; endoscopic closure could
represent a less invasive alternative for fistula closure.
Technological advances in new accessories for
gastrointestinal tract endoscopy have expanded treatment
options in difficult situations. The OVESCO
® clip, with its
capability to grasp more tissue, was first used in NOTES
(
5,
6) and found to be an excellent option for treating
gastrointestinal tract haemorrhage (
7), large perforations
and post-operative fistulae (
8). Various published studies
on the endoscopic applications of the OVESCO
® clip in the gastrointestinal tract have reported promising results,
particularly in porcine models (
9-13). Our patient’s fistula
was narrowed, but not completely closed, by the placement
of only an OVESCO
® clip; subsequent intra-fistula injection
of cyano-acrylate led to complete sealing of the fistula
despite the fact that the continuous passage of urine (not
eliminated by a bladder catheter) and the fibrotic tissue of
the fistula did not contribute to this outcome.
A recent review of the application of standard metallic
cl ips in the management of ga st rointest ina l t rac t
perforations occurring during diagnostic and therapeutic
endoscopy indicated that the use of these clips to treat small
iatrogenic perforation is feasible. Moreover, they could
reduce costs and time of hospitalisation and avoid patients
having to undergo a surgical repair (
14). However, although skilled endoscopists can find standard clips easy to use, they
are difficult to manage in cases with a fistula diameter > 1
cm, because of the problems of aligning the wound margins
(
15,
16), and in cases in which the surrounding tissue is
fibrotic, such as the case of rectovesical fistulae.
The major advantage of OVESCO® clips seems to be their
ability to grasp more tissue compared to the standard clips
and their strong grip on the wound margins, because of
their sharpened teeth. The drawback of the clips in fistula
sealing is their incomplete grasp when the tissue is fibrotic.
The new OVESCO® clip, in association with a cyanoacrylate
injection in the case of incomplete clinical success,
appears to be an excellent endoscopic therapeutic option
in the subgroup of patients with anastomotic leak, without
abdominal abscess, avoiding surgery in these patients. We,
therefore, suggest trying an endoscopic approach to the
treatment of rectovesical and anastomotic fistulae before
referring a patient for the surgery.
