{"paper_id":"28440ffc-f3ce-4d26-b960-3cd3c1e18ba9","body_text":"Endoscopic closure of a rectovaginal fistula following surgery\nfor endometriosis using the MARCEAU system\nA rectovaginal fistula is a rare condi-\ntion and a therapeutic challenge [1].\nEndoscopic closure requires combined\napproaches with both mucosal ablation\nand mechanical closure of the fistula [2].\nAs reported in a recent multicenter study,\nthe novel “fistula endoscopic submucosal\ndissection with clip closure ” (FESDC)\nstrategy is safe and feasible for endo-\nscopic closure of gastrointestinal fistulas\n[3]; however, in our population, the tech-\nnical success does not exceed 70 % in\nnaïve fistulas. We previously reported\nthe optimal results of a new closure de-\nvice called the “mucosal adaptative ring\nto close endoscopic artificial ulcer ” (MAR-\nCEAU) in endoscopic leak closure at the\nulcer bed after endoscopic submucosal\ndissection (ESD) and persistent gastro-\ncutaneous fistulas after percutaneous\nendoscopic gastrotomy [4, 5]. This strat-\negy has not previously been used for\ngynecological fistulas.\nWe herein report the case of a 31-year-\nold woman referred for a rectovaginal\nfistula after a colonic resection for endo-\nmetriosis, which had caused severe infec-\ntions (chorioamniotitis leading to miscar-\nriage). A sigmoidoscopy was performed,\nand the fistulous orifice appeared in the\nrectum, with passage of air and blue in\nthe vagina (\n▶ Video 1 ). ESD of the sur-\nrounding mucosa was performed to facil-\nitate fistula closure and the MARCEAU\ndevice was used to close the fistula. This\ndevice is made from anti-return sutures\n(VLOC; Medtronic, USA) with a loop that\ncan be pulled, thereby closing the loop\nprogressively (\n▶ Fig. 1). The system was\nfixed to two edges of the ulcer by clips.\nMultiple clips were then placed side by\nside capturing the sealing device. Finally,\nall of the clips were closed up to each\nother by tightening the device with a for-\nceps (\n▶ Fig. 2). An MRI performed 3\nmonths after the procedure confirmed\nthe closure of the fistula.\nThis technique seems attractive in chal-\nlenging situations, s uch as gynecological\nfistulas, to ensure a firm and sustained\nclosure of the leak. The low cost and\nease of use of this device combined with\nlower risks than surgery could allow\nmore widespread use.\nEndoscopy_UCTN_Code_TTT_1AQ_2AG\nCompeting interests\nThe authors declare that they have no con-\nflict of interest.\nThe authors\nElena De Cristofaro 1, Pierre Lafeuille 2\n ,L o u i s -\nJean Masgnaux 2, Olivier Rouquette 3,A n n e -\nSophie Grémeau 4, Jérôme Rivory 2,M a t h i e u\nPioche 2\n1D e p a r t m e n t o f S y s t e m s M e d i c i n e ,\nGastroenterology and Endoscopy Unit,\nUniversity of Rome Tor Vergata, Rome, Italy\n2 Department of Endoscopy and\nHepatogastroenterology, Pavillon L, Edouard\nHerriot Hospital, Lyon, France\nE-Videos\nVideo 1 Rectovaginal fistula treated with MARCEAU device.\n▶ Fig. 1 The MARCEAU device is shown in: a a drawing (1, edge loop; 2, hemoclip; 3, addi-\ntional fixation loop; 4, fixed point for one edge; 5,6, tightening wire with the loop to grasp\nand pull); b a photograph.\nDe Cristofaro Elena et al. Endoscopic closure of … Endoscopy 2023; 55: E1023 –E1024 | © 2023. The Author(s). E1023\nArticle published online: 2023-09-01\n\n3 Department of Endoscopy and\nHepatogastroenterology, Clermont-Ferrand\nUniversity Hospital, Université Clermont\nAuvergne, Clermont-Ferrand, France\n4 Department of Gynecology, Clermont-\nFerrand University Hospital, Université\nClermont Auvergne, Clermont-Ferrand,\nFrance\nCorresponding author\nMathieu Pioche, MD, PhD\nEndoscopy Unit, Department of Digestive\nDiseases, Pavillon L – Edouard Herriot\nHospital, 69437 Lyon, France\nMathieu.pioche@chu-lyon.fr\nReferences\n[1] Willingham FF, Buscaglia JM. Endoscopic\nmanagement of gastrointestinal leaks and\nfistulae. Clin Gastroenterol Hepatol 2015;\n13: 1714 –1721\n[2] Bertrand G, Jacques J, Rivory J et al. Deep\nendoscopic submucosal dissection of a re-\nfractory tracheoesophageal fistula using\nclip-and-line traction: a successful closure.\nEndoscopy 2017; 49: 1278 –1280\n[3] Lafeuille P, Wallenhorst T, Lupu A et al.\nEndoscopic submucosal dissection com-\nbined with clip closure is effective to close\ngastrointestinal fistulas including refractory\nones. Endoscopy 2022; 54: 700 –705\n[4] Masgneaux L, Yzet C, Grimaldi J et al. Endo-\nscopic closure of the ulcer bed after endo-\nscopic resection using the “mucosal adap-\ntive ring to close an endoscopic artificial\nulcer ” (MARCEAU) procedure. Endoscopy\n2022; 54 (Suppl. 02): E1076 –E1077\n[ 5 ] G r a uR ,P i o c h eM ,R i v o r yJe ta l .E n d o s c o p i c\nclosure of a gastric perforation using muco-\nsal adaptative ring to close endoscopic arti-\nficial ulcer: the MARCEAU system. Endos-\ncopy 2023; 55 (Suppl. 01): E297 –E298\nBibliography\nEndoscopy 2023; 55: E1023 –E1024\nDOI 10.1055/a-2155-3708\nISSN 0013-726X\n© 2023. The Author(s).\nThis is an open access article published by Thieme under the\nterms of the Creative Commons Attribution License, permit-\nting unrestricted use, distribution, and reproduction so long\nas the original work is properly cited.\n(https://creativecommons.org/licenses/by/4.0/)\nGeorg Thieme Verlag KG, Rüdigerstraße 14,\n70469 Stuttgart, Germany\n▶ Fig. 2 Schematic view of the “mucosal adaptive ring to close an endoscopic artificial ulcer ”\n(MARCEAU) device showing: a fixation of the device at the edge of the ulcer; b clipping along\nthe ulcer; c closure of the ulcer by tightening the device with a forceps.\nENDOSCOPY E-VIDEOS\nhttps://eref.thieme.de/e-videos\nE-Videos is an open access online\nsection of the journal Endoscopy,\nreporting on interesting cases\nand new techniques in gastroenterological\nendoscopy. All papers include a high-quality\nvideo and are published with a Creative\nCommons CC-BY license. Endoscopy\nE-Videos qualify for HINARI discounts and\nwaivers and eligibility is automatically\nchecked during the submission process.\nWe grant 100% waivers to articles whose\ncorresponding authors are based in Group\nA countries and 50% waivers to those\nwho are based in Group B countries as\nclassified by Research4Life (see: https://\nwww.research4life.org/access/eligibility/).\nThis section has its own submission\nwebsite at\nhttps://mc.manuscriptcentral.com/e-videos\nE1024 De Cristofaro Elena et al. Endoscopic closure of … Endoscopy 2023; 55: E1023 –E1024 | © 2023. The Author(s).\nE-Videos","source_license":"CC0","license_restricted":false}