Treatment of chronic colorectal fistula with the over-the-scope-clipping system : a case report

1 Center of Oncosurgery, National Cancer Institute, 1 Santariskiu Str., LT-08406 Vilnius, Lithuania 2 Vilnius University Hospital, Santariskiu Clinics, 2 Santariskiu Str., LT-08661 Vilnius, Lithuania 3 Center of Oncosurgery, National Cancer Institute, Clinic of Internal, Family Medicine and Oncology, Faculty of Medicine, 1 Santariskiu Street, LT-08406 Vilnius, Lithuania E-mail: o.aliosin@gmail.com


Introduction
All colorectal surgeons in their practice are faced with an anastomotic leakage after colorectal surgery.Anastomotic leakage after colorectal resection is a rare complication, but it has a significant mortality (6-22%) [1].The standard treatment is a diverting ileostomy for 2-3 months with the subsequent recanalization only when a radiological contrast study shows that the fistula has disappeared [2].About 6 years ago, a new over-thescope clip system, called OTSC (Ovesco Endoscopy, Tubingen, Germany), appeared on the market.It was first tested on animal models and by treating lesions and bleeding from the GI tract [3,4].
We report the case of a male patient with a suture insuftiency and a fistula after colorectal cancer surgery, which was successfully treated by endoscopy.

Case report
A 63-year-old male was admitted to our institute, complaining of defecation with blood.Cancer in the middle part of the rectal ampulla was found during clinical examinations.After examination and multidiscipline team consultation, neaodjuvant radiotherapy was applied.
After 5 days of a short course of radiotherapy (25Gy), a low anterior resection with a total mesorectal excision of the defunctioning ileostomy was performed.The distance from the anastomosis to the anal verge was 5 cm.The early postoperative period was uneventful, and the patient was discharged from the hospital on day 7.
On the 9 th day after surgery, the patient was admitted complaining of urine retention, and transcutaneous epicytostomy was performed.Later, the patient complained of a dull pelvic pain, febrile temperature and some liquid discharge through the anus.On contrast proctography, a presacral sinus of 10 x 9 x 4 cm and a leakage of a short loop limb after side-to-end anastomosis of about 2 cm were found (Figure 1).On endoscopy, a defect in the bowel wall was seen (Figure 2).Since he had a defunctioning ileostomy, conservative therapy was prescribed.After 6 months of unsuccessful conservative management, the patient was offered a closure of the large bowel wall defect with the OTSC system.For a week he did not complain of any liquid discharge through the anus.On the 30 th day after clip application, the defect was still marked, but it was smaller.The OTSC clip was removed and another clip applied (Figures 3 and 4).The patient did very well, one month later the proctography was normal, and the ileostomy was closed.

Discussion
For the patients after colorectal surgery who develop a leakage, the treatment becomes long and sometimes complicated.Defuntioning ileostomy is not enough in some cases.After the OTSC system application, the patient can be treated as an outpatient.In our case, only the second application of an OTSC clip was successful.Looking through reports, the success rate of the OTSC system procedure for the insuftiency of anastomosis or colorectal fistulas was 50-100% [5], but only less than 10 successful reports of chronic colorectal fistulas were found [2,6,7].In terms of cost, conservative therapy alone versus conservative therapy plus the OTSC clip are comparable.
In conclusion, the application of OTSC appears to be useful in the endoscopic management of colorectal postsurgical leaks and fistulas.Further prospective clinical studies are needed to confirm the value and efcacy of this clipping device.

Figure 1 .
Figure 1.Contrast radiography showing a cave of 10 x 9 x 4 cm and a leak of about 2 cm

Figure 2 .
Figure 2. The same anastomotic defect seen on endoscopic evaluation