CASE STUDY Endoscopic placement of self-expandable metal stents for treatment of rectovaginal fistulas after colorectal resection for cancer Antonietta Lamazza, MD, Enrico Fiori, MD, Antonio V. Sterpetti, MD, FACS, FRCS Rome, Italy A postoperative rectovaginal fistula is a rare adverse event after colorectal resection for cancer. 1,2,3 In these clin- ical situations, the most common etiology derives from a pelvic abscess, determined by a leaking anastomosis, which drains externally through the posterior wall of the vagina. The first issue is to exclude recurrent cancer as the cause of the fistula. Repair through the anus 4,5 is successful when the tissue looks normal and is pliable, but this is rarely the case. Sometimes, a flap should be transposed be- tween the vagina and the rectum, by using a muscle like the gracilis or the labium majus (associated or not to the overlying skin and/or to the underlying bulbo-cavernous muscledso-called Martius flap). 6,7 Severe inflammation, widespread infection, friability of the vaginal and rectal tissue, and inevitably reduced blood perfusion to the rectum make any form of treatment haz- ardous. 8 Even in case of healing of the fistula, there is a high possibility of residual stricture and altered colorectal motility. Here, we report the clinical course of 6 patients with rectovaginal fistulas after colorectal resection for cancer, treated with endoscopic placement of self-expandable metal stents (SEMSs). MATERIAL AND METHODS Patient characteristics Six consecutive patients with rectovaginal fistulas after colorectal resection for cancer were selected to have endoscopic placement of SEMSs. Patients had a complete evaluation, including low-pressure barium enema, pelvic CT scan, and endoscopy with multiple biopsies, to exclude recurrent or residual cancer. Clinical characteristics The mean age of the 6 women was 53.5 years (range 36-75 years). All had anterior resections with staples for cancer. All patients had preoperative radiotherapy. In 4 pa- tients, endoscopic stenting was the first line of treatment, and none had a proximal diverting ileostomy. In these 4 patients, the procedure was performed from 25 to 40 days after the original operation, after failed conserva- tive treatment. The remaining 2 patients were referred to us after multiple failed operations to repair the fistulas. These 2 patients had intestinal stomas performed else- where. The stenting procedures were performed 75 and 85 days, respectively, after the original colorectal resections. Anatomic characteristics All patients had a history of fever, high white blood cell count, and abdominal distension, which were partially resolved as soon as the rectovaginal fistulas were clinically evident. CT scans showed, in all cases, a pelvic abscess draining externally through the vagina. Multiple biopsies did not show any evidence of residual or recurrent cancer. Stenting procedure Signed informed consent was obtained from all patients. A pediatric nasogastroscope (Olympus GIF N180 4.8 mm in diameter; Olympus, Tokyo, Japan) was used to pass the anastomosis. In such a way, it is possible to have direct vision of the anatomy and pathology and to pass the guide- wire above the anastomosis through the nasogastroscope. This has made the procedure much simpler and faster and, theoretically, given it a reduced risk of perforation or bleeding. A standard colonoscope was not used because of its larger size and the risk of enlarging the fistula. The SEMS apparatus was placed at the level of the anastomosis through the guidewire previously inserted and finally was deployed under fluoroscopic guidance. We used fully covered colonic stents 10 cm in length, 28 mm in diameter (Tae Woong Medical Corp, Gimpo-si, Gyeonggi-do, South Korea) in 5 patients. In the remaining patient, an Abbreviation: SEMS, self-expandable metal stent. DISCLOSURE: All authors disclosed no financial relationships relevant to this publication. Copyright ª 2014 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 http://dx.doi.org/10.1016/j.gie.2014.01.010 Received November 20, 2013. Accepted January 6, 2014. Current affiliations: Departement “Pietro Valdoni”, Sapienza University of Rome, Rome, Italy. Reprint requests: Antonietta Lamazza, Antonio V Sterpetti, Policlinico Umberto I, Viale del Policlinico 00167 Rome, Italy. www.giejournal.org Volume -, No. - : 2014 GASTROINTESTINAL ENDOSCOPY 1