IPEG 2020 TOP ABSTRACT: Laparoscopic takedown of an ileocolic fistula.

This case is a laparoscopic takedown of an ileocolonic fistula with primary closure and diverting loop ileostomy. Our patient is a 17 year old male with newly diagnosed Crohn's disease. He presented to the emergency department with perforation. CT scan showed presacral, perirectal, and ileosoas abscesses. Prior to this presentation, he had a presumed diagnosis of ulcerative colitis. He was started on IV ciprofloxacin and Flagyl. And underwent IR guided drainage of the abscesses. He failed to have complete resolution of his abscesses with drains. So CT enterography was performed which demonstrated an ileosigmoid fistula. Decision was made to take the patient for a diagnostic laparoscopy. The patient was positioned in a modified Lloyd Davies position. After entry into the abdomen, the terminal ileum was identified. Here you'll note the sigmoid colon is adherent to the pelvic side wall. Here, as indicated by the tip of the suction device, you can appreciate the ileosigmoid fistula. Once the fistula was located, we identified a window posterior to the bow that allowed a Penrose drain to be placed for upward traction and isolation of the fistula. Here you can see us taking down the adhesions connecting the sigmoid colon to the pelvic side wall. Once those are freed, now we clearly see the isolated ileosigmoid fistula. After upsizing our umbilical port from 5 millimeter to 12 millimeter, we then passed a stapler across the fistula to divide it. Given the severity of disease, we elected to imbricate our staple line, as you see here. Next, a leak test was performed. Here you can see the insulation of the bowel using rigid proctosigmoidoscopy, and note no bubbles are seen at the site of repair. The right lower quadrant abdominal port site was used to grasp the small bowel proximal to the fistula. This was then matured into a diverting loop ileostomy. After the procedure, the patient was started on Remicade. He underwent upper endoscopy several months later, which demonstrated a normal duodenum, but gastritis secondary to emesis. Colonoscopy was performed, which revealed patchy areas of erythematous mucosa at the hepatic flexure with an area of pouching concerning for a possible fistula. It also revealed abnormal mucosa in the rectum, sigmoid, and descending colon. However, tissue pathology from these areas revealed normal mucosa. 4 months later, the patient underwent a barium enema study. It was normal caliber throughout the entire colon. No stricture, no abnormal dilation. No fistula was identified. Due to patient's disease-free mapping via endoscopy and barium enema study, he underwent a laparoscopic ileocystectomy with primary ollocholic anastomosis 8 months later. Patient. Continues to do well 5 months post procedure. His Remicade was resumed 2 weeks after his initial postoperative visit.