Post written by Malay Sharma, MD, DM, from the Jaswant Rai Specialty Hospital, Meerut, Uttar Pradesh, India.
A 35-year-old man presented with recurrent urinary tract infection requiring multiple courses of antibiotics for the past 15 years. He had undergone surgery for an imperforate anus at birth, and an anal stricture developed, which required repeated bougienage dilation until he was 4 years of age. After anal dilation, he had intermittent passing of urine through the anal opening and received a diagnosis of anourethral fistula. He underwent repeated fistulectomy with urethral repair but became symptomatic again after remaining well for 4 years. He was reluctant to undergo further surgery. Radial EUS showed a tortuous fistula in the anal canal communicating with the prostatic urethra. A linear EUS-guided glue injection was planned. The patient was catheterized before glue injection to obtain better visualization of the fistula tract and avoid leakage of glue into the urethra at the time of glue injection. Under EUS guidance, glue was injected into the middle part of the fistula. During the glue injection, the Foley catheter was rotated clockwise and counterclockwise to avoid glue sticking to the catheter. The rotation of the catheter was continued for 1 minute after 0.5 mL of cyanoacrylate injection. The fistula tract was successfully closed. The patient was symptom-free at his 1-year follow-up visit.
Figure 1. A, Radial EUS view showing presence of air bubbles in the fistula. B, EUS view showing Foley catheter in prostatic urethra. C, EUS view showing Foley catheter in membranous urethra. D, EUS view showing Foley catheter in penile urethra. E, All 4 parts of the urethra. F, Glue injection into the anourethral fistula with a 22G needle.
Perianal fistula as an adverse event of anal canal surgery occurs infrequently. They are usually treated surgically. We report for the first time in literature a EUS-guided management of a case of postsurgical perianal fistula with cyanoacrylate glue injection.
EUS-guided cyanoacrylate glue can be safely attempted to treat postsurgical anourethal fistulas. The procedure is easy and cost effective, with no significant morbidity. However, more cases by interventional endoscopists are required to know the potential advantages and disadvantages of this new technique.
This case shows the potential advantages of EUS guided treatment of fistulas. Interventional endosonographers can further explore this new area of therapeutic EUS.
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