Endoscopic management of malignant ileovesicular fistula

Kachaamy PortraitToufic Kachaamy, MD, from the Western Regional Medical Center at Cancer Treatment Center of America, Goodyear, Arizona, USA, presents this video case “Successful endoscopic management of a malignant ileovesicular fistula.”

A 56-year-old man with history of metastatic colon cancer and prior treatment with subtotal colectomy, ileostomy, and multiple lines of chemotherapy presented with a few weeks of vomiting and a few days of fecaluria. Computed tomography showed a rectal mass invading the terminal ileum and urinary bladder with air in the urinary bladder consistent with an enterovesicular fistula. Small bowel follow through demonstrated the location of the fistula. Malignant enterovesicular fistula cause recurrent urinary tract infections and severe dysuria. They are often associated with a distal obstruction creating a high pressure system favoring the formation of the fistula. Surgical management requires radical surgery and is associated with high morbidity and mortality. Endoscopic management was offered to the patient with consideration of placement of a covered stent.

An enteroscopy was performed through the ileostomy and the malignant mass invading the small bowel was identified. The fistula track was identified and confirmed fluoroscopically with contrast injection showing extravasation into the urinary bladder. The distal obstruction was identified. A covered metal stent was placed with the distal end at the ileostomy and sutured distally to the skin to decrease the risk of migration. The patient symptoms of vomiting and fecaluria resolved immediately with stenting. The stent migrated 2 months later with recurrence of his fecaluria. The migrated stent was replaced with partially covered stent which was again sutured in place. There was no further stent migration. The patient expired from his disease without recurrence of his symptoms 4 months later. Radiographic confirmation of successful results was demonstrated with the lack of contrast extravasation on small bowel follow through after stenting.

An enterovesicular fistula is a rare manifestation of malignancy. This case discusses signs and symptoms in addition to pathognomonic radiographic findings which will help a gastroenterologist recognize and diagnose this condition. It also shows a methodical approach to tackling this complex endoscopic problem.

Malignant fistula are often associated with a distal obstruction favoring the formation of the fistula. Identifying the obstruction is important as relieving it helps with relieving the high pressure system which otherwise will favor flow into the fistula. In addition, if stenting is undertaken, the obstruction can help anchor the stent in place. This case highlights the use of a covered esophageal stent in the small bowel. Currently in the United States, covered small bowel stents are unavailable. The stent used here can alternatively be used when covering a fistula is needed.

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The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.

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