V3 - Endoscopic Management of Postoperative Rectal Stump Leak: Innovation With a Modified TGJ Tube

Rectal stump is prone to leakage from its staple line resulting in pelvic abscess with significant morbidity and mortality. With no standardized treatment on rectal stump leakage (RSL), timing of diagnosis and extent of contamination are crucial in guiding management.

Case Description/

Methods:

A 41-year-old female with ulcerative colitis presented with RSL as post-op complication after abdominal colectomy and Hartmann pouch creation. She had a transcutaneous drain placed to control the leak which was draining hemopurulent fluid despite antibiotics therapy. CT showed a bilobed rim-enhancing fluid collection in the pelvis. Given recent surgeries and ongoing chronic pelvic infections, the endoscopy team was consulted to optimize the patient before any surgical intervention. On pouchoscopy, a diffuse area of rectum was congested, inflamed, and ulcerated (figure1A). The rectal cuff had a disrupted staple line which was continuous with an abscess cavity where the transcutaneous drain was present (figure1B,1C). The decision was made to replace the existing drain with a modified prosthesis so that we can irrigate and suction the cavity while obtruding the disrupted staple line. To create the prosthesis, balloon from an 18 Fr TGJ tube was removed to use the balloon port for irrigation and the G-port for cavity decompression. Then a PEG tube bumper was sutured to the tube such that when placed, the bumper obtrudes the staple line. We created holes in the jejunal extension of the tube which was used for short-chain fatty acid (SCFA) irrigation of the rectal stump to promote healing. Under fluoroscopic guidance, the drain was removed, and the existing tract was used to pass this modified TGJ tube (figure2A). After confirming placement, contrast was passed through the balloon port which outlined the abscess cavity with no passage in the rectal stump. Then, suctioning the G-port removed the contrast from the cavity. We then passed contrast transrectally which outlined the rectal stump with no leakage into the cavity, thus confirming occlusion by the PEG tube bumper (figure2B). The patient was educated on using this set-up for irrigation of the tract (balloon port), decompressing the tract (after attaching the gastric port to bulb suction) and instillation of SCFA (jejunal port). She is being monitored for follow-up.

Discussion:

With surgical options not feasible, we describe a case of RSL management with an innovative endoscopic technique of utilizing a TGJ tube and PEG bumper to optimize patient condition.