An intestinal fistula is a common and serious complication of intestinal surgery (1), which can occur in patients of any age. In a meta-analysis, Gefen et al (2) reported that 89.4% of patients postoperatively developed an enterocutaneous fistula. The most common fistula site was the small bowel, followed by the colon. The underlying etiologies for enterocutaneous fistula development were inflammatory bowel disease (IBD), malignancy and radiation, and the incidence rate of postoperative intestinal fistula in patients without major basic diseases was markedly reduced (2). Regardless of the surgical context, intestinal fistulas pose a considerable challenge as a postoperative complication. The etiology of intestinal fistula encompasses a range of factors, including abdominal trauma, cancer, radiation, IBD and infectious diseases, and is often accompanied by complications such as sepsis, malnutrition and electrolyte disorders. Complex intestinal fistulas, accounting for ~28% of cases, pose a significant challenge for surgeons (2,3).

Notably, successful management and early treatment of intestinal fistulas are crucial to achieve good treatment outcomes (2). When an intestinal fistula occurs, patients may experience pain and severe skin discomfort. If not handled appropriately, intestinal failure caused by intestinal fistula and the series of complications it causes can be fatal. The treatment of intestinal fistulas includes conservative and surgical strategies, which usually have a significant negative impact on the quality of life of patients. Various treatment modalities have been employed to treat patients with intestinal fistulas, including total parenteral nutrition. Additionally, surgical intervention, such as the placement of vacuum-assisted closure devices, fibrin glue application, endoscopic procedures and repeated ostomy, may be utilized. However, it is important to note that the cure rate and effectiveness of these interventions can vary. Reoperation, mainly open and laparoscopic, is occasionally necessary for severe and complex intestinal fistulas; however, laparoscopic surgery is technically difficult, and adhesions around the secondary surgery are extensive, complicating the surgery. Open surgery causes significant trauma, and patients may experience recurrent fistulas or require colostomy, which reduces their quality of life. Currently, there are limited effective and minimally invasive treatment plans for patients with intestinal fistulas (4,5).

Intestinal fistula treatment can take several months or even years, and is cumbersome and complex (6). The prolonged duration of treatment, coupled with the nature of the treatment, can result in psychological and physical trauma. Conservative approaches typically prove ineffective and time-consuming. Additionally, secondary surgical interventions for stoma reconstruction can impose further physiological stress on patients. Moreover, there exists considerable psychological pressure on patients with stomas, with a number of patients expressing reluctance to accept such a solution (7). Hence, opting for minimally invasive treatment methods becomes crucial, aiming to spare patients from undergoing additional stoma procedures, and alleviating both physical and psychological burdens. Herein, the present study describes the case of a patient with a postoperative gastrointestinal fistula. Through the use of transurethral prostate resection instrumentation, intestinal stent placement and drainage was enabled. After multiple minimally invasive treatments spanning 6 months, the patient recovered and was discharged.

The patient underwent a full course of treatment for 6 months and ultimately recovered after five surgical procedures. The latter four of these were minimally invasive procedures that did not introduce more complications or cause pain to the patient. Various techniques and surgical procedures for treating intestinal fistulas have been reviewed (2,5,8). Conservative treatment is usually the preferred treatment option initially; however, patients with severe intestinal fistulas cannot be cured through conservative treatment, and their condition can worsen and thus put their lives at risk. Furthermore, surgical enterostomies can increase trauma and pain.

Notably, ≥28% of patients with intestinal fistulas have a complex fistula, which is identified as more than one abnormal connection between the gastrointestinal tract and the skin, or a fistula involving multiple bowel loops. Studies have described a 44-100% success rate of fistula treatment methods, including fibrin glue, vacuum-assisted closure devices, over-the-scope clip endoscopic treatment and extracellular matrix plug; however, the number of patients in the studies were too small to draw a meaningful conclusion about the efficacy of these techniques (9-12). A total of 31 studies involving 1,381 patients have reported fistula healing in 44.8% of the patients who received conservative treatment (2). The fistula recurrence rate after any type of treatment was revealed to be 15.1% in 41 studies (2,557 patients) and the mortality rate was 9.6% (2). After surgery for fistulas, the fistula recurrence rate was 7.6%, the hernia recurrence rate was 19.7% and the infection rate at the surgical site was 36.5%. Mortality was primarily associated with the general condition of the patients, including the presence of sepsis and advanced cancer, malnutrition, American Society of Anesthesiologist score, fistula recurrence and tobacco smoking (2,13-16).

In the present case, before being admitted to Hexi University Affiliated Zhangye People's Hospital, the patient underwent partial resection of the transverse and descending colons, and ileostomy. Consequently, colonic leakage poses a risk of abdominal abscess formation. Urgent surgical intervention and prompt treatment of the infection are imperative in such scenarios. The intestinal continuity can be restored after complete infection control; therefore, acting hastily may not be advisable, as it could exacerbate pain and increase the risk of complications, particularly in cases of direct colostomy.

Treatment of intestinal fistulas requires a multidisciplinary approach (17,18). In the second stage of treatment in the present study, we collaborated with the urology team to perform an endoscopy using transurethral prostate resection instrumentation under direct vision through the upper abdominal incision opening without anesthesia. Placing a drainage tube in the intestinal tract and rinsing it with physiological saline is beneficial for wound healing. Transurethral prostate resection instrumentation, in which a hard endoscope is used to guide resection, is commonly used in urology. The compact design of the endoscope facilitates easy handling during procedures. This instrument provides high-pressure flushing of the operative field, thereby ensuring optimal visibility. Moreover, the insertion of a guidewire catheter in transurethral prostate resection instrumentation is comparatively less invasive than laparoscopy, and offers greater convenience and simplicity compared with colonoscopy (19,20). Patients may experience postoperative complications, such as recurrent fistula, infection or intestinal failure after laparoscopic and open surgical procedures. Therefore, systemic nutrition, which is the most important and first step in treatment, is crucial in these patients. During instrument exploration, the patient receives minimally invasive treatment without the need for anesthesia; thus, there was no risk of surgical and anesthetic complications for the patient. If minimally invasive treatment is ineffective, open surgery can be performed, as it is the only hope for patient survival or cure. It has previously been reported that instrument-based exploration can effectively treat intestinal diseases (21). Therefore, the same prostate resection endoscopy instrumentation was reused for the exploration, treatment and insertion of drainage stents. After sufficient intestinal recovery, satisfactory treatment results were achieved. Although the patient in this case had good treatment outcomes and did not experience postoperative complications or recurrence, this was an isolated case because there were no other patients who underwent such treatment. Therefore, it is not possible to determine the success rate of the treatment options, which is a limitation of the present study.

In the present case, the treatment in each stage was slow and orderly. First, the infection was controlled and intestinal drainage was performed. Once intestinal continuity was fully restored, the patient underwent small intestinal recovery surgery. While the surgical procedures served a crucial role, it is important to note that they were just one aspect of the thorough treatment approach. The treatment of intestinal fistulas requires comprehensive treatment, and the initial focus should be on dealing with water-electrolyte-balance disorders, and actively preventing and treating infection and sepsis. Adjusting the patient's physiological and psychological state is optimal, and effective parenteral nutrition support is essential. Patients with complex intestinal fistulas can be cured through sufficient minimally invasive drainage.

In conclusion, endoscopic guidance for intestinal stent placement to promote intestinal recovery is a simple, effective and minimally invasive treatment plan for complex intestinal fistulas. At present, there are several treatment options for intestinal fistulas, including conservative and surgical treatment, but each has its advantages and disadvantages. The treatment cycle is long, and the therapeutic effect is uncertain, which is a major challenge faced by surgeons. This case report offers valuable insights into employing a comprehensive approach for treating complex intestinal fistulas using a colon indwelling drainage stent under the guidance of transurethral prostate resection instrumentation. By integrating multiple techniques along with interdisciplinary collaboration, this method demonstrates efficacy in managing such challenging cases. Leveraging commonly utilized urological equipment proves to be particularly advantageous, streamlining procedures and yielding significant outcomes with minimal effort in patients undergoing general surgery. The limitations of specialization of surgeons and departments can be effectively addressed through interdisciplinary collaboration, benefiting more patients.