Management of a rectovesical malignant fistula with the coated wallstent

There are little data in the literature regarding the management of rectovesical fistula. Expandable stents have been used in the palliation of colorectal malignant strictures. We present a case of a rectovesical fistula that developed in the setting of a malignant rectal stricture managed with the coated Wallstent (Schneider, Minnesota). The patient was a 46 yo man who had the diagnosis of unresectable rectal cancer for 16 months with local and distant metastases, treated with chemotherapy. Endoscopy revealed a 6 cm long exophytic stricture with a lumen of 25 mm. Eight months later he developed colonic obstructive symptoms. Endoscopy revealed an exophytic 6 cm long stricture with a lumen of 5 mm that started about 3 cm above the dentate line. As an outpatient, a 90 mm long 22 mm lumen enteral Wallstent was placed with an excellent symptomatic response. A barium enema 1 week later showed a patent stent. Two weeks after placement, he developed fecaluria and worsening of his pelvic pain. A rectovesical fistula just distal to the stent was demonstrated by barium enema, being the stent patent and in good position. At endoscopy, a partially occluded stent by granulation tissue distally and by tumor ingrowth in the mid-stent was found. The fistula could not be seen. As an outpatient, a 90 mm coated Wallstent was inserted through the original stent extending beyond its margins. The most caudal end of the second stent was approximately 15 mm above the dentate line. The patient had complete resolution of the fecaluria and moderate improvement of the pelvic pain. A contrast study showed the fistulous tract to be sealed off. Besides rectal tenesmus and 4-5 continent bowel movements a day, the patient had no further gastrointestinal symptoms until his death 3 months later. In conclusion, this case demonstrates that coating of enteral stents is necessary to prevent tumor ingrowth and that colorectal malignant fistula can be successfully treated with the coated Wallstent. A study using colorectal stents is underway.