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PubMed1999

Abdominal closure using nonabsorbable mesh after massive resuscitation prevents abdominal compartment syndrome and gastrointestinal fistula.

Patients who receive high-volume resuscitation after massive abdominopelvic trauma, or emergent repair of a ruptured abdominal aortic aneurysm (RAAA), are at a significant risk for postoperative abdominal compartment syndrome (ACS). Absorbable prosthetic closure of the abdominal wall has been recommended as a means of managing ACS. However, use of absorbable prosthetic has been associated with very high rates of intestinal fistula formation and ventral hernia formation. The purpose of this study was to retrospectively review our experience with the use of nonabsorbable prosthetic abdominal closures in patients with documented ACS or at high risk for ACS. All patients managed by this technique from July 1995 through July 1997 after repair of ruptured abdominal aortic aneurysm or massive abdominopelvic trauma were evaluated. A total of 18 patients were identified: 15 primary prosthetic placements (Gore-Tex patch, 12; Marlex mesh, 2; and silastic mesh, 1) and 3 delayed prosthetic placements for ACS (Gore-Tex, 1 and Marlex, 2). The mortality rate was 22 percent (4 of 18) and resulted from multisystem organ failure (2 patients), cardiac arrest 1 hour postoperatively (1 patient), and severe closed head injury (1 patient). Secondary closure and prosthetic removal was possible in 16 of 18 patients, including the 2 patients who died of multisystem organ failure within the same hospitalization. Delayed abdominal closure at a subsequent admission was performed in two cases. This same patient developed an enterocutaneous fistula 2 months after discharge. Importantly, only 1 of 18 closed in this manner developed ACS requiring reoperation. The results indicate that use of a nonabsorbable prosthetic, particularly with Gore-Tex, is efficacious in the prevention of postoperative ACS in high-risk patients, while it enhances the possibility for delayed abdominal closure and minimizes the risk of gastrointestinal fistulization associated with other techniques.

Abdominal Injuries↗
PubMed2003

Manifestation, latency and management of late urological complications after curative radiotherapy for cervical carcinoma.

BACKGROUND: Radiotherapy alone or in combination with radical hysterectomy remains a potentially curative treatment for cervical carcinoma. Late urological complications after curative radiotreatment are rare but often present difficult problems of management due to the progressive nature of radiogenic tissue damage. We reviewed all cases of radiogenic urologic complications after radiotherapy for cervical carcinoma treated at our institution over the past 10 years. PATIENTS AND METHODS: In a retrospective analysis, out of all female patients treated for hydronephrosis (n = 543), 93 patients with hydronephrosis occurring after curative treatment for gynecological malignancies were identified. The most frequent cause was progressive disease (n = 55); 30 patients without recurrence had severe radiogenic urological complications (study population). RESULTS: Out of 30 patients with a mean age of 44.9 years at the time of treatment for cervical cancer, 6 had undergone primary radiotherapy and 24 had received adjuvant radiotreatment after radical hysterectomy. The observed late urological complications were: distal ureteral stenoses (bilateral in 4 cases, unilateral in 15 cases), distal ureteral necrosis (n = 1), bilateral ureteral reflux (n = 3), vesico-vaginal fistulae (n = 5), vesico-intestinal fistula (n = 1), severe fibrotic bladder shrinkage (n = 6) and urethral stenosis (n = 2). Marked signs of radiogenic cystitis were observed in almost all patients. The mean latency time between radiotherapy and manifestation of severe radiogenic urological sequelae was 19.4 years (range 0.5-41.5). Primary treatment of urological complications consisted in temporary urinary diversion by percutaneous nephrostomies or insertion of internal ureteral stents. Permanent treatment for radiogenic ureteral stenosis in all patients with sufficient general health consisted of surgical or endourological urinary diversion or reconstruction. However, the majority of patients were managed by permanent endourological measures. Lower tract fistulae were treated by distal ureteral occlusion and diversion. CONCLUSIONS: Although severe late urological sequelae of curative radiotherapy for cervical carcinoma are rare they represent major complications, result in considerable distress for the patient, and often present difficult therapeutic problems for the urologist. As these urological complications can have extremely long latency times, focussed follow-up for early detection may be advisable.

Adult↗
PubMed2004

Late complications of incisional hernias following prosthetic mesh repair.

BACKGROUND: Incisional hernias still continue to be a serious problem for surgeons. In this study, we aimed to investigate the effects of polypropylene mesh and mersilene mesh, which are frequently employed in incisional hernias, as well as the effects of their application techniques on late complications. METHODS: Two-hundred-sixty-four open abdominal hernia repairs were performed between 1986--2000, using prosthetic materials: polypropylene mesh and mersilene mesh were used in hernia repair. Mesh was placed as onlay, underlay and sandwich techniques. Follow-up data were obtained from medical records. RESULTS: Comparisons were made with respect to surgical techniques and to late complications such as recurrence, enterocutaneous fistula, intestinal obstruction, and infections. Enterocutaneous fistulas developed in two patients. Recurrence occurred in 6.4 per cent. Chronic infection and wound sinus formation occurred in 5 per cent. The causes of recurrence included smoking, cellulitis, chronic infection/sinus tract, upper abdominal localization, and obstruction. Fistula formation occurred in patients with no peritoneal prevention, which was statistically significant (p=0.012). Chronic infection/sinus tract was high in patients for whom mersilene mesh was used, and enterocutaneous fistula occurred in 2 patients. CONCLUSION: To prevent late complications, it is necessary to avoid the contact of mesh with bowel.

Abdomen↗
PubMed2001

[Abdominal wall defects caused by postoperative infections].

Infectious defects of the abdominal wall often result from deeper subfascial infections of the abdominal wall caused by a persisting intraabdominal inflammation or the result of laparotomy in peritonitis. Therapies applied are first of all the removal of the sources of infection and a careful debridement of the abdominal wall. There are several ways of temporarily covering the abdominal wall, but there is no ingenious solution. In our own experience the application of zip fastening and PGS nets have proved successful. In case of deeper infections of the abdominal wall the most awkward situation is the laying open of small intestine loops in a granulating wound which may lead to a revitalization of chronic small intestine fistulae. In these cases a differentiated and repeated surgical approach and extensive resection of small intestine parts, and consequently a high rate of complications and lethality cannot be avoided. Extensive defects of the abdominal wall exposing parts of small intestines after such operations require temporary covering and in this case we use Vypro net which, under the most favourable circumstances, can represent a final solution.

Abdominal Muscles↗
PubMed2003

[Cholestatic icterus during parenteral nutrition and the therapeutic effect of enteral feeding--case report].

An acute operation was made on a 56-year woman for inflammatory perforation of colon. A series of repeated operations followed due to relapsing iatrogenic intestinal fistula and peritonitis. From the day 70 the patient was treated at the Intensive Metabolic Care Unit of the Gerontological and Metabolic Clinic of Faculty Hospital in Hradec Králové. Having cured the septic shock the authors prepared the patient to a reconstruction operation on alimentary tract by administering parenteral nutrition, treating the wounds and by motion rehabilitation. From day 150 on the patient was treated with low doses of enteral nutrition into the segment of intestine between the fistulas, in connection with the subsequent decrease of two-month lasting hyperbilirubinemia of 200-260 mumol/l. A successful reconstruction of the alimentary tract was performed on the day 205 of the treatment with the time lapse of 146 days after the last surgical intervention. A three-fold anastomosis on small intestine and a resection of the fistula on the transversal colon was made. The post-operation fistula was healed-up conservatively, while the parenteral nutrition continued, as verified on day 246 by enteroclysis. The paper draws attention to the importance of conservative metabolic care in the therapy of dishiscences of intestinal anastomoses not treated by acute surgery in time. A favourable additive effect of enteral nutrition on the persisting cholestasis during parenteral nutrition is discussed.

Cholestasis↗
PubMed1992

Treatment of enterocutaneous and colocutaneous fistulas with early surgery or somatostatin analog.

Standard therapy of enterocutaneous (ECF) and colocutaneous (CCF) fistulas consists of "conservative" management, with surgery reserved for failures of maximal medical treatment. We conducted a five-year retrospective review of 28 patients with low-output ECF and CCF to determine the outcome of early surgical and nonsurgical treatment of these conditions. Twelve men and 16 women with a mean age of 60 years presented with 22 ECF and 6 CCF. Six patients had early operative intervention in an attempt to close their fistulas, while the remaining 22 patients were treated without surgery. In addition, four of the nonsurgical group received parenteral somatostatin analog (SA). None of the surgical patients was septic preoperatively (mean WBC = 9.7), the mean preoperative hospital stay was 11 days, and no patients required a proximal diverting stoma. All of the surgical group resumed normal gastrointestinal function within two weeks, and seven of the nine (78 percent) demonstrated no recurrence of the fistula at a mean follow-up of 8.3 months. Of the 22 medically treated patients, three of the four who received SA healed their fistulas within two weeks. Only two of the other 13 medically treated patients (15 percent) healed their fistulas. Early surgery or the use of SA should be considered in the treatment of patients with low-output intestinal fistulas.

Colonic Diseases↗
PubMedDate not supplied

Successful treatment of enterocutaneous fistula in a premature newborn by using octreotide.

A premature newborn with an enterocutaneous fistula after repair of duodenal perforation is reported to emphasize the therapeutic effect of octreotide in persistent fistula even in a very small infant. Our report showed that use of octreotide was safe even in premature infants with intestinal fistula. Close monitorization of biochemical and blood parameters is needed in patients treated with octreotide.

Gastrointestinal Agents↗
PubMed1980

[Treatment of gastrointestinal disease with elemental diets (author's transl)].

Elemental diets are ballast-free formula diets, which are fully resorbed in the upper jejunum, and which do scarcely stimulate gastric, pancreatic or bile secretion; they contain no antigens, decrease intestinal work load, and do influence most probably the composition of the intestinal bacterial flora in a quantitative as well as qualitative way. Therefore such dietary preparations are used in gastrointestinal diseases. Their indications have not yet been clarified sufficiently by controlled therapeutic trials, however they are used with apparent success, especially in ulcerative colitis and Crohn's disease, in malabsorption syndromes, and in patients with intestinal fistula.

Colitis↗
PubMed1977

[2 variants of angular enterostomy].

To accelerate the self-healing of an intestinal fistula the author developed 2 variants of enterostomy based on the principle of valvular closure of the serous canal after the removal of the tube. The serous canal around the tube forms from the lateral walls of both bends of intestinal loop a fold in the shape of an angle. In the first variant the tube enters the intestinal lumen along the intestinal loop curvature line; in the second - through the lateral wall of one of the intestinal loop bends. The angular jejunostomy was applied as feeding fistula in 49 cases. The angular ileostomy was carried out on 24 cases to obtain the decompression of the small intestine. There were no cases of complications or fatal outcome resulting from the application of the angular enterostomy method.

Humans↗
PubMed2004

Expression and localisation of matrix metalloproteinases and their natural inhibitors in fistulae of patients with Crohn's disease.

BACKGROUND: Fistulae are a troublesome complication of Crohn's disease but little is known of the final effector molecules responsible for matrix degradation. Although matrix metalloproteinases (MMPs) have been strongly implicated in tissue injury in Crohn's disease, their role in fistula formation is unknown. AIM: To determine the expression pattern of MMPs and tissue inhibitors of metalloproteinases (TIMPs) in fistulae of patients with Crohn's disease. PATIENTS AND METHODS: Resected fistula specimens were obtained from patients with Crohn's disease (n = 11) and classified according to the predominant histological features-that is, acute versus chronic inflammation. Patients with fistulae due to other diseases (n = 9) and normal colon (n = 5) served as controls. MMP and TIMP protein expression was measured by single or double labelled immunohistochemistry, and mRNA expression by in situ hybridisation. MMP activity was measured by gelatin zymography. RESULTS: Compared with normal colon, strong MMP-3 expression was consistently observed in fistulae in Crohn's disease, irrespective of the stage of inflammatory activity. MMP-3 transcripts and protein were localised in large mononuclear cells and fibroblasts. MMP-9 transcripts and protein were expressed in granulocytes and only in fistulae with acute inflammation. Staining for MMP-1 and MMP-7 was weak and negative for MMP-10, whereas MMP-2 was equally expressed in normal colon and fistulae. TIMP-1, TIMP-2, and TIMP-3 expression was low in all samples. Similar expression patterns were found in fistulae of the disease control group. Fistulae also expressed active MMP-2 and MMP-9, as measured by gelatin zymography. CONCLUSION: MMP-3 and MMP-9 are markedly upregulated in intestinal fistulae and may contribute to fistula formation through degradation of the extracellular matrix, irrespective of the underlying disease process.

Adolescent↗
PubMed1992

[Foreign bodies in the rectum and colon].

On the basis of analysis of treatment of 80 patients with foreign bodies of the rectum and colon, the volume and character of the therapeutic measures required were defined. The endoscopic methods for removal of the foreign bodies, peculiarities of extraction of the large foreign bodies are presented. The cases of penetration of the foreign bodies into the colon via a natural, or artificial intestinal fistula are described.

Adolescent↗
PubMed2005

An intestinal volvulus caused by multiple magnet ingestion: an unexpected risk in children.

It has been reported that ingested magnets can cause intestinal fistula formation or perforation, leading to intestinal obstruction. However, there are no previous case reports that magnet ingestion additionally caused an intestinal volvulus. We report herein the case of a 1-year-old boy in whom the ingested magnets caused a volvulus of part of the small intestine leading to the resection of the necrotic portion. We think that if more than one magnet is found as a foreign body in the intestine, they should be removed immediately by laparotomy. Clinicians who care for children should be aware of this unexpected risk.

Foreign Bodies↗