Freehand Endoscopic Fistulotomy Guided by Perineal Ultrasound in Crohn's Perianal Abscess: A Day-Care Alternative to Surgery Allowing Continuation of Biologics

An 18-year-old male with fistulizing Crohn's disease involving the ileocolonic region and rectum had a right-sided intersphincteric fistula at the 11 o'clock position, managed previously by endoscopic seton placement. 1After three induction doses of infliximab, he presented with pain, induration, and purulent discharge from the left perianal region (at the 3 o'clock position).The next infliximab dose was due in 1 week.Point-of-care transperineal ultrasound (TPUS; Linear probe 2-9 MHz, Samsung RS80 EVO, Samsung India Electronic Pvt.Ltd.) revealed a 10 9 9 mm hypoechoic abscess without fistulous communication (Fig.1A, B).Accurate point-of-care TPUS avoided the need for costly magnetic resonance imaging (MRI) pelvis, which is often requested before intervention and can delay treatment.On the same day, under conscious sedation, endoscopic freehand fistulotomy was performed using a needle knife (Boston Scientific, Marlborough, United States) connected to an electrosurgical generator (VIO 300D, ERBE Elektromedizin GmbH, Tbingen, Germany) with Endocut I current (effect 3, cut duration 1, cut interval 3). 2 The knife was held freehand between the index finger and thumb like a pen, rather than through-the-scope, to make two stellate mucosal incisions over the indurated area, facilitating pus drainage (Fig.1C, F; Video 1).