INTRODUCTION

Recto-vaginal fistula (RVF) is a rare complication after Hartmann's intervention, with little evidence regarding non-surgical alternatives, particularly in fragile patients who are unfit for major surgery.

ENDOSCOPIC PROCEDURE

A 78-year-old woman, functionally dependent due to cognitive impairment, had undergone Hartmann's intervention for sigma volvulus after three unsuccessful endoscopic detorsion attempts. Two years later, she was readmitted with sepsis and rectal bleeding. CT imaging revealed spontaneous perforation of the rectal stump, a presacral collection and suspicion of a RVF. Rectoscopy showed diversion colitis and a 10mm fistulous orifice with purulent/fecaloid drainage. Partial exploration of the tract was possible, and rectovaginal communication was confirmed by vaginal examination. Given her condition, conservative management (antibiotic therapy) was initially chosen; however, she experienced multiple readmissions due to sepsis secondary to recurrent urinary tract infections. Faced with the surgical contraindication, an Amplatzer luminal aposition device of 14 x 18 mm was deployed with support from Cardiology under fluoroscopic guidance, using rectal access (conventional gastroscope) and vaginal access (pediatric gastroscope). A guidewire was advanced through the fistula, and the device was released under dual endoscopic vision. Subsequently, the patient evolved favourably, with no further septic episodes or Emergency Department visits.   

DISCUSSION

Post-Hartmann RVF in elderly patients with comorbidities imposes a therapeutic challenge. Evidence on endoscopic closure of RVF with cardiac devices (Amplatzer) is scarce, although promising cases have been reported in collovaginal and rectal fistulas. This case illustrates the feasibility of a minimally invasive strategy in patients with surgical contraindication, achieving fistula closure and clinical improvement, whit no septic recurrences after the procedure.