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PubMed2000

[Esophageal perforation and postoperative fistulae of the upper digestive tract treated endoscopically with the application of Tissucol].

We present three patients with serious gastro-esophageal complications which were treated with Tissucol. The first patient developed a rare postoperative oesophago-pleural fistula. The second suffered a traumatic esophageal perforation (possibly iatrogenic) that was discovered at the end of the removal procedure of an alimentary bolus impacted in the distal esophagus. Attempts to close the high output oesophago-pleural fistula with standard treatment were unsuccessful. It was closed with Tissucol at the third attempt, in conjunction with oesophago-jejunal stenosis by means of endoscopic dilatation. In the second patient, early Tissucol application after detection of pneumomediastinum was an effective complementary treatment to the conservative approach and rapidly closed the perforation. The third patient developed a low debit postoperative gastro-cutaneous fistula that did not resolve with conservative treatment. It was closed with only one session of Tissucol sealing. We consider that the endoscopic application of fibrin glue should become the first step in the conservative treatment of small esophageal perforations or postoperative esophageal pleural fistulae, especially in cases of high output fistulae. The success of this technique depends on the localization and selective catheterization of the fistula and on brushing the fistular opening. Total resolution of any distal stenosis is necessary to prevent reopening of the fistula.

Adult↗
PubMed2006

Duodeno-pleural fistula: a rare complication of peptic ulcer perforation.

Duodenopleural fistula is a very uncommon complication of peptic ulcer perforation and usually follows empyema after a subdiaphragmatic abscess rupture. We present a rare case of duodenopleural fistula following subdiaphragmatic abscess, which resulted in thoracic empyema after gastric perforation.

Adult↗
PubMed2006

The Kraske procedure: a critical analysis of a surgical approach for mid-rectal lesions.

BACKGROUND AND OBJECTIVES: To analyze the Kraske procedure as an approach to mid-rectal disease. METHODS: Twenty-two patients underwent a Kraske procedure at either Duke University Medical Center, the Durham Veterans Administration Medical Center, or the Durham Regional Hospital between 1992 and 1997. The clinical and pathologic characteristics of these patients were retrospectively analyzed and compared with previous published series. RESULTS: Of the 22 patients, 13 underwent resection of an adenocarcinoma and 9 underwent resection of a villous adenoma. Post-operative complications included four fecal fistulas (two of which required a temporary diverting colostomy), two wound infections, two cases of urinary retention, and one case of transient fecal incontinence. CONCLUSIONS: The Kraske procedure minimizes exposure of mid-rectal lesions without the morbidity of a major laparotomy. However, it does carry a moderate complication rate and thus should be utilized selectively in managing patients with mid-rectal tumors not amenable to other treatment options.

Adenocarcinoma↗
PubMed2006

[Sonographic diagnosis of a liver abscess caused by an enterohepatic fistula in a patient with Crohn's disease].

Liver abscesses in patients with Crohn's disease are rare. We report on a patient with Crohn's disease and a liver abscess of the left lobe caused by an enterohepatic fistula. With treatment of antibiotics and Infliximab the abscess showed complete regression. Percutaneous drainage of the liver abscess was not performed because the abscess was shown not to be completely liquefied at echo-enhanced ultrasound. This case report demonstrates the usefulness of percutaneous conventional and echo-enhanced ultrasound for the diagnosis of liver abscesses. Furthermore, this case also shows that enterohepatic fistulas can be diagnosed precisely with percutaneous ultrasound.

Adult↗
PubMed2002

[Management of enteric fistula].

OBJECTIVES: To evaluate the essentials for successful management of entero-cutaneous fistulas and their. METHODS: We analyzed. The therapeutic results of 1 168 cases treated in a single center from January. 1971 to December. 2000. RESULTS: In these patients, the cure rate of fistulas was 93% and 37.1% after non-operative treatment. Most cases died of sepsis (60/65 cases, 93.2%) with a total mortality of 5.5%. In 659 cases who had undergone operation for enteric fistula, 647 (98.2%) recovered. The cure rate, mortality rate and successful rate of operation (94.2%, 4.4%, 99.7%) in the period of January. 1985 - December. 2000 were better than those (90.4%, 8.2%, 95, 5%) in the early period of January 1971 December 1984 (P < 0.05). CONCLUSIONS: The change of therapeutic strategy, improved technique in control of sepsis, rational nutritional support and careful monitoring of vital organs are essential to the management of enteric fistulas. How to increase the spontaneous closure of fistula, the therapeutic rate of specific enteric fistula (e.g. IBD, radiation enteritis) and the operative rate of enteric fistula in the early period requires further study.

Adolescent↗
PubMed2001

New technique of laparoscopic-assisted excision of a cholecystocolic fistula: report of a case.

Cholecystocolic fistula is a rare complication of gallstone disease that is most commonly diagnosed at the time of surgery. It is generally considered to be a contraindication to laparoscopic cholecystectomy because of the difficulties involved in its management intraoperatively. Laparoscopic stapling or suturing techniques have been reported as feasible and safe methods for repairing such fistulas; however, these procedures are not always able to be performed due to technical difficulties. We exteriorized a cholecystocolic fistula through an umbilical incision, whereby it was repaired safely and easily. This report describes our new technique for managing a cholecystocolic fistula found incidentally during a laparoscopic cholecystectomy.

Cholecystectomy, Laparoscopic↗
PubMed2003

Treatment of early duodenal fistula after orthotopic liver transplantation: a case report.

Gastrointestinal fistula as a serious complication could lead to imbalance of nutrition or death. Duodenal fistula after orthotopic liver transplantation is rare and its treatment is complicated. On April 28, 200, we performed orthotopic liver transplantation for a patient at our hospital. Eight days after operation duodenal fistula developed, but cured after 13-day treatment.

Debridement↗
PubMed2006

[Unusual postoperative fistula of the abdominal wall, caused by an ingested wooden spit perforating the intestine and lodging itself in the abdominal wall].

Abdominal fistula caused by an ingested wooden spit, which penetrated the intestinal wall and remained in the abdominal wall: a laparascopy was performed in a 41-year-old man suffering from acute appendicitis and an inflamed Meckel's diverticulum. After removal of the appendix and the diverticulum, a fistula developed in the excision channel of the left quadrant of the abdominal wall post-operatively. Despite repeated incision of the abscess in the course of 2 months, the fistula did not heal. Ultrasound examination of the abdominal wall was therefore performed. The postoperative status was without conspicuous findings. We could, however, detect a foreign body, a few centimetres long and 2-3 mm thick, displaying a smooth surface, deep down in the abdominal wall. A fistulography confirmed the diagnosis. After removal of the wooden spit, complete healing of the fistula in the abdominal wall was observed. Subsequently, the patient reported to have eaten a beef roulade, fixed with a wooden spit, 7 weeks before the abdominal operation.

Adult↗
PubMed2000

Risk factors for intra-abdominal sepsis after surgery in Crohn's disease.

PURPOSE: This study examined risk factors for intra-abdominal sepsis after surgery in Crohn's disease. METHODS: We reviewed 343 patients who underwent 1,008 intestinal anastomoses during 566 operations for primary or recurrent Crohn's disease between 1980 and 1997. Possible factors for intra-abdominal sepsis were analyzed by both univariate (chi-squared test) and multivariate (multiple regression) analyses. RESULTS: Intra-abdominal septic complications, defined as anastomotic leak, intra-abdominal abscess, or enterocutaneous fistula, developed after 76 operations (13 percent). Intra-abdominal septic complications were significantly associated with preoperative low albumin level (< 30 g/l; P = 0.04), preoperative steroids use (P = 0.03), abscess at the time of laparotomy (P = 0.03), and fistula at the time of laparotomy (P = 0.04). The intra-abdominal septic complication rate was 50 percent (8/16 operations) in patients with all of these four risk factors, 29 percent (10/35 operations) in patients with three risk factors, 14 percent (14/98 operations) in patients with two risk factors, 16 percent (33/209 operations) in patients with only one risk factor, and 5 percent (11/208 operations) in patients with none of these risk factors (P<0.0001). The following factors did not affect the incidence of septic complications; age, duration of symptoms, number of previous bowel resections, site of disease, type of operation (resection, strictureplasty, or bypass), covering stoma, and number, site, or method (sutured or stapled) of anastomoses. CONCLUSIONS: Preoperative low albumin level, steroid use, and the presence of abscess or fistula at the time of laparotomy significantly increased the risk of septic complications after surgery in Crohn's disease.

Abdomen↗
PubMed2000

[A case of colon cancer with tension pneumothorax and empyema as a consequence of colo-pleural fistula].

A 63-year-old man was admitted to our hospital with fever and chest pain. Chest radiography revealed left pleural effusion with left pneumothorax and small nodular shadows in the right lung field. On CT of the chest and abdomen, multiple nodules were seen in both lung fields, and masses appeared in the liver and spleen. Fiberoptic colonoscopy showed obstruction at the end of the transverse colon. Biopsy of this obstruction proved it to be cancer. In this patient, a colo-pleural fistula was also diagnosed using thoracoscopy under local anesthesia and from the inflow of contrast medium from the colon into the thoracic cavity seen in abdominal radiographs. This was a rare case of a colo-pleural fistula without diaphragmatic deficiencies. Medical thoracoscopy is useful for the diagnosis of complicated pleural effusions as was seen in this case.

Anesthesia, Local↗
PubMed2002

Perforations and fistulae in gastrointestinal tuberculosis.

BACKGROUND: Perforation and fistulae, though uncommon, are serious complications of gastrointestinal tuberculosis. Patients with acute tuberculous perforation are subjected to surgery, whereas localized perforation and fistulae with subtle clinical signs are detected by barium contrast examination. There has been no report on radiological series regarding the incidence of perforation and fistulae, detected by barium contrast studies. MATERIAL AND METHODS: A retrospective analysis of barium contrast studies of 684 proven cases of gastrointestinal tuberculosis seen over a period of 15 years was done to detect the incidence of perforation and fistulae. RESULTS: Fifty-two patients (7.6%) with localized perforation and fistulae were seen. Twenty-eight patients had evidence of perforation, and 24 patients showed fistulae formation. The most common site of perforation and fistulae was the small bowel followed by the colon. Associated abnormalities noted were ulcerations, strictures, nodular filling defects and extrinsic compression. CONCLUSION: Perforation and fistulae along with other associated abnormalities of the gastrointestinal tract are suggestive of tuberculosis, particularly in a population predisposed to tuberculous infection.

Adolescent↗
PubMed1998

Metastases involving the gastrointestinal system.

OBJECTIVES: To provide a review of metastases involving the gastrointestinal system, including the specific problems of liver metastasis, bowel obstruction, ascites, biliary obstruction, and gastrointestinal fistulas. DATA SOURCES: Research studies, review articles, and book chapters. CONCLUSIONS: When metastasis involves the gastrointestinal tract, the emotional distress is coupled with debilitating symptoms and marked nutritional deficits. Treatment decisions must consider potential benefits and risks and affect on quality of life. IMPLICATIONS FOR NURSING PRACTICE: An understanding of the disease process and alternative treatment interventions will assist nurses to effectively anticipate and manage symptoms that may develop and educate patients and families so they can participate in decisions regarding their treatment.

Ascites↗
PubMed2006

Pulse granulomas detected in gallbladder, fallopian tube, and skin.

CONTEXT: Foreign material typically elicits reactions dominated by multinucleated giant cells. Pulse granulomas are peculiar reactions to particles of food that are characterized by clusters of small to medium-sized hyaline rings. Pulse granulomas are rare and have occupied only the lungs, in association with aspiration, and the alimentary canal, in association with oral pathology, colonic diverticula, and a rectal mass. OBJECTIVE: To report pulse granulomas that occupied previously unrecognized sites and to alert pathologists to the diagnostic pitfall of mistaking pulse granulomas for other entities. DESIGN: We retrospectively reviewed 3 recently encountered cases that involved pulse granulomas in the gallbladder, fallopian tube, and skin. RESULTS: In all cases, pulse granulomas were associated with fistulae involving the gastrointestinal tract. One fistula was clinically occult. Microscopy showed barium-laden histiocytes admixed with hyaline rings, with or without vegetable matter, confirming fistulae involving the gastrointestinal tract. Absence of other features of chronicity, including sarcoid-type granulomas and Langhans-type giant cells, helped to essentially exclude Crohn disease. In 1 case, hyaline rings of pulse granulomas closely resembled hyaline vasculopathy of amyloidosis, diabetes, or hypertension. Surprisingly, polariscopy failed to detect any vegetable matter. In 1 case, negative polariscopy contributed to the difficulty in finding rare vegetable matter. CONCLUSIONS: We demonstrated that pulse granulomas can occur outside the lungs and alimentary canal, and can be associated with fistulae involving the gastrointestinal tract. Awareness of this finding is necessary to avoid confusion with Crohn disease and hyaline vasculopathy. Polariscopy may fail to detect vegetable matter.

Aged↗
PubMed1999

Use of somatostatin in the treatment of digestive fistulas. Pharmacoeconomic issues.

The management of high-cost surgical patients with digestive fistulas is a major health problem. Second to total parenteral nutrition, somatostatin has been considered the most dramatic advance in the control of fluid, electrolyte and nutritional embarrassment caused by such fistulas. Native somatostatin, first isolated in 1973, is a 14-amino acid peptide with a half-life of 1-3 min, and numerous inhibitory effects on the secretion of digestive fluids. Several nonrandomized trials have shown that somatostatin enhances the closure rate and reduces the time to closure of almost all types of digestive fistulas. Somatostatin, if used appropriately, seems to be associated with overall cost savings mainly by decreasing the length of hospital stay. Prospective controlled trials are expected to confirm these findings in the near future.

Cost Savings↗
PubMed1999

Management of digestive tract fistulas. A review.

Digestive tract fistulas are a complex subject in terms both of classification and management. There is still a lack of firm epidemiological data regarding the their incidence, though the prognostic factors conditioning the prognosis of these patients are now well known. They are related mainly to the nutritional status of the patients and to the presence or otherwise of sepsis. Instrumental investigations should be aimed not merely at identifying the complication, but also at guiding clinicians in their choice of therapeutic management. According to the various situations arising, the treatment will be surgical, endoscopic or conservative medical. In the latter case, the clinician should establish first of all whether, as a result of the site of the fistula or the nutritional status, the patient requires total parenteral or enteral artificial nutrition, whenever possible. In those cases in which parenteral nutrition is indicated, the ideal drug with the best proven ability to shorten healing times and reduce the number of complications when used in combination with parenteral nutrition is naturally occurring somatostatin at the dose of 250 micrograms/h over 24 h. In all other cases, if the fistula is clinically important, its synthetic analogue, octreotide, should be the drug of choice and can be administered subcutaneously. The amount of octreotide administered ranges from 300 to 600 micrograms/day in 3 or 4 daily doses.

Digestive System Fistula↗
PubMed2004

[Pyogenic liver abscess in chronic alcoholic pancreatitis].

HISTORY AND ADMISSION FINDINGS: A 44-year-old patient was transferred for further treatment of pyogenic liver abscess and a severe attack of a chronic pancreatitis for strong upper right quadrant abdominal pain and recurring fever. INVESTIGATIONS: Laboratory results revealed a significant inflammatory constellation. Abdominal ultrasound was performed which showed a big pyogenic abscess in the right lobe of the liver. Escherichia coli and Enterococcus faecalis could be isolated from abscess aspirates. Endoscopic retrograde cholangiography (ERC) without access of the pancreatic duct showed stenosis of the Ductus hepatocholedochus which was treated with a biliary endoprothesis. DIAGNOSIS, TREATMENT AND COURSE: Antibiotic treatment and percutaneous drainage led to complete remission of the abscess. A few days after discharge the patient returned with identical clinical symptoms. Abdominal ultrasound showed recurrence of the abscess. Because of excessively high pancreatic amylase in aspirated abscess material the patient underwent endoscopic retrograde cholangiopancreaticography (ERCP). There, a pancreatico-hepatic fistula was seen, probably the result of necrosis caused by a severe acute attack of the chronic pancreatitis. After insertion of a naso-fistular drainage, continous rinse and appropriate antibiotic therapy both abscess and fistula completely disappeared without recurrence. CONCLUSION: The rare case of a pancreatic fistula should be considered when a pyogenic liver abscess follows an episode of acute pancreatitis or attack of chronic pancreatitis. Determination of pancreatic amylase in aspired abscess material can be an important step towards correct diagnosis.

Adult↗
PubMed2005

Fistula-in-ano: do antibiotics make a difference?

BACKGROUND: The objective of this study was to evaluate the hypothesis that antibiotics in conjunction with drainage of anorectal abscesses will reduce the incidence of fistulae formation. The impact of age and associated comorbidity on the formation of fistulae were also evaluated. METHODS: Patients with a diagnosis of anorectal abscesses were identified from the database of a single colorectal practice. Demographic data, comorbidity, antibiotic usage, and fistulae formation were collected from review of patient's charts and phone contact. Statistical analysis was performed with the two-sided Fisher's exact and Wald's chi-square tests. RESULTS: Fifty-six patients with complete data were analyzed. The overall fistulae formation rate was 32%. Of all patients, 45% received a course of broad-spectrum antibiotics at the time of drainage and 48% of patients had associated comorbidity. Although trends were evident, there were no statistical significant associations between fistulae formation and age, comorbidity, and antibiotics. CONCLUSION: Although not statistically significant, there was a trend that antibiotics and age >45 years may be protective against the formation of fistulae. Similarly, the data suggest that the presence of comorbidity may increase the risk of fistula formation. We are encouraged by this result and propose to conduct a larger randomized prospective study.

Abscess↗