CASE STUDY Endoscopic treatment of postsurgical colorectal anastomotic leak (with videos) Francisco Pérez Roldán, MD, 1 Pedro González Carro, MD, 1 María Concepción Villafáñez García, MD, 2 Sami Aoufi Rabih, MD, 1 María Luisa Legaz Huidobro, MD, 1 Esther Bernardos Martín, MD, 1 Rosanna Villanueva Hernández, PhD, 1 Emilia Tebar Romero, PhD, 1 Francisco Ruiz Carrillo, MD 1 Alcázar de San Juan, Spain The treatment of rectal cancer has evolved in recent years, and several neoadjuvant chemotherapy and radiotherapy regimens have been combined with less-expensive surgical approaches. However, these techniques also involve post- surgical adverse events, namely, colorectal stricture, rectocu- taneous fistula, and suture dehiscence. 1,2 The frequency of these adverse events varies among studies. Postsurgical rectal fistula and dehiscence are not un- common findings in low anterior resection performed to treat rectal cancer. 1,2 The initial approach is usually con- servative. 2 The lesion can be cleaned and fibrin glue can be injected endoscopically. 3,4 Hemoclips, over-the-scope clips (Ovesco), and endoloops can also be used to join the edges of the fistula or dehiscence. Finally, Polyflex-type (Boston Scientific, Natick, Mass) plastic stents 5,6 or coated metal stents are an additional option. 7 Sponges have also proved successful in the treatment of rectal dehiscence. 8-10 Biodegradable expandable polydioxanone stents (coated and uncoated) are a new therapeutic option 11-14 that en- ables the repair of a fistula or dehiscence of the anasto- mosis, thus, in theory, facilitating scar formation. 7 We report our experience with biodegradable stents com- bined with other endoscopic approaches to repair post- surgical fistula and dehiscence. PATIENTS AND METHODS We conducted a retrospective and descriptive observa- tional study. The sample comprised 5 consecutive patients included from November 2010 to November 2011 with a diagnosis of postsurgical fistula or dehiscence after colo- rectal resection to treat adenocarcinoma of the rectum that was refractory to conservative approaches. Because none of the patients wished to undergo further surgery, they were all offered endoscopic repair on a compas- sionate basis by using approved treatment options. In- formed consent was obtained before the procedures were undertaken. Conservative treatment involved waiting for spontane- ous resolution, correcting clinical and electrolytic disor- ders, prescribing bowel rest, improving nutrient depletion, and using broad-spectrum antibiotics. In the case of fistu- lae, the skin surrounding the fistula was protected. In addition, factors that could adversely affect spontaneous closure of the fistula or dehiscence were investigated to correct them. If the conservative approach was not suc- cessful after at least 1 month, the patient was offered the option of surgery. Endoscopy equipment and accessories The fistula or dehiscence was examined by using high- definition colonoscopy (EC-3870K; Pentax Europe GmbH, Hamburg, Germany). The stent was fitted by using a 0.035- inch guidewire (450 cm long) (Jagwire Straight TIP, 0.035 inch  450 cm; Boston Scientific, Alajuela, Costa Rica), which was inserted by using the colonoscope. The guide- wire was then was left in place, and a high-definition gastroscope (EG-2770K; Pentax Europe GmbH) was used to insert the different catheters to apply cyanoacrylate, fibrin, hemoclips, or a polyurethane sponge. An ultraslim endo- scope (EG-1870K; Pentax Europe GmbH) was necessary in some cases to ensure a suitable opening for the stent. Radi- ography was not necessary to ensure a correct opening for the stent because no stricture was present and the entire process could be monitored by using direct endoscopy. The biodegradable stents used were coated poly-p- dioxanone stents. The coating was internal and made of polyethylene. We used the biodegradable SX-ELLA esopha- geal stent, which measures 31/25/31 mm in diameter; its length varied with the size of the dehiscence (ELLA-CS s.r.o., Hradec Králové, Czech Republic). The fully covered metal DISCLOSURE: The authors disclosed no financial relationships relevant to this publication. Copyright © 2013 by the American Society for Gastrointestinal Endoscopy 0016-5107/$36.00 http://dx.doi.org/10.1016/j.gie.2013.01.043 Received October 5, 2012. Accepted January 24, 2013. Current affiliations: Departments of Gastroenterology (1) and Emergency Medicine (2), Hospital General La Mancha Centro, Alcázar de San Juan, Spain. Reprint requests: Francisco Pérez Roldán, MD, Department of Gastroenter- ology, Hospital General La Mancha Centro, Avenida de la Constitución, 3 13600-Alcázar de San Juan. Spain. www.giejournal.org Volume xx, No. x : 2013 GASTROINTESTINAL ENDOSCOPY 1