V20 - From Flare to Repair: Robotic Management of a Crohn’s-Related Enterovesical Fistula

CME Eligible

Purpose/Background: Enterovesical fistulas are a challenging complication of recurrent penetrating Crohn's disease. Multidisciplinary care is key, and a minimally invasive approach is a viable approach to complex recurrent penetrating disease.

Methods/Interventions: Methods/Interventions
We present a robotic takedown of an enterovesical fistula of the blind end of a prior side-to-end (Baker) ileosigmoid anastomosis to the bladder in a patient with complex, recurrent, fistulizing Crohn's disease.

Results/Outcomes: Results/Outcomes
This is a 29-year-old male with a history of non-adherence to medical therapy resulting in poorly controlled fistulizing Crohn's disease. He had a subtotal colectomy with ileosigmoid anastomosis 6 years prior. He presented with pneumaturia with imaging consistent with multiple fistulous connections between the small bowel that made up the blind end of the anastomosis with the bladder. Preoperatively, the patient underwent a flexible sigmoidoscopy, MRE, medical optimization with antibiotics, and bowel rest with TPN.
Intraoperatively, dense adhesions were encountered between the bladder, small bowel, and omentum. The blind limb of the prior ileosigmoid anastomosis was identified as the site of fistulization and carefully dissected off the bladder. A flexible sigmoidoscopy confirmed the fistula location and healthy appearance of the prior ileosigmoid anastomosis. The blind end was then excluded and resected with a stapler. ICG confirmed excellent perfusion at the staple line, and leak tests of the bladder and bowel were negative.

The patient had an uneventful postoperative period. The CT cystogram was negative for a bladder leak, and he was discharged home on postoperative day 3.

Conclusion/Discussion: Conclusions
The minimally invasive takedown of an enterovesical fistula in a Crohn's patient is feasible and safe. Multidisciplinary approach, careful preoperative optimization, cautious dissection, and intraoperative endoscopic assessment can facilitate successful outcomes in complex fistulizing disease.