V48 - Over-the-Scope Clip Management of Anastomotic Leak in Crohn's Disease

CME Eligible

Purpose/Background: Over-the-scope clip (OTSC) system is an endoscopic mechanical clipping device with increasing use in refractory gastrointestinal hemorrhage, perforations, luminal defects, anastomotic leaks, and fistulas. Studies have shown up to 80% clinical success rates in closure of anastomotic leaks, but there is limited data on use in patients with inflammatory bowel disease. We present a case in which OTSC was used to close an anastomotic leak after a re-do ileocolectomy for Crohn's disease.

Methods/Interventions: Patient is a 71-year-old male with history of Crohn's disease with prior ileocolectomy and small bowel resection roughly 30 years ago. He presented with abdominal pain, nausea, bilious emesis, and unintentional weight loss of 40lbs. He was found to have recurrence with fibrostenotic structuring at the ileocolic anastomosis that was not traversable on colonoscopy. He therefore underwent an open re-do ileocolectomy. Three weeks later, he returned to the ED with abdominal pain, leukocytosis, and CT scan showing a large abscess and a small tract extending from the anastomosis indicative of an anastomotic leak. After percutaneous drain placement by interventional radiology, patient was taken to the OR for a colonoscopy, fluoroscopy, and endoscopic closure of the anastomotic leak. The stapled side-to-side antiperistaltic ileocolic anastomosis was initially inspected with a colonoscope. The colonic side of the stapled corner and the ileocolic anastomosis appeared intact. The stapled corner on the ileal side had a small opening with evidence of purulent fluid. An intraoperative fluoroscopy showed extraluminal contrast through this defect, consistent with a leak. The colonoscope was withdrawn and a 1T therapeutic scope was advanced with the end cap and clip in place. The mucosa at the defect edge was healthy without endoscopic evidence of active inflammation. The scope was then positioned such that the opening was located in the center of the end cap. Gentle suction was applied to pull the mucosa into the end cap circumferentially. The over-the-scope clip was then deployed. There was good tissue apposition, and the anastomosis remained widely patent.

Results/Outcomes: Patient had an uncomplicated post-procedure course with repeat CT scan showing resolution of the leak on day 3. He was then discharged to rehab on antibiotics. He was seen in outpatient follow-up roughly 3 weeks later with CT showing decrease in the collection, and the percutaneous drain was subsequently removed.

Conclusion/Discussion: This case presentation demonstrates the utility of over the scope clip system to treat a 71-year-old male who presented with an anastomotic leak 3 weeks after a re-do ileocolectomy for Crohn's stricture. Over-the-scope clip system can be a safe and effective treatment option for anastomotic leak in patients with inflammatory bowel disease.