Mexican consensus on the integral management of digestive tract fistulas. Ixtapa-Zihuatanejo, Mexico, August 21-23, 1997.
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Digestive System Fistula↗
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18-fluorodeoxyglucose positron emission tomography as a novel imaging tool for the diagnosis of aortoenteric fistula and aortic graft infection--a case report.
The diagnosis of aortic graft infection and aortoenteric fistula can be difficult to establish using conventional radiographic imaging modalities. Positron emission tomography (PET) imaging with 18-fluorodeoxyglucose (FDG) can rapidly provide anatomically clear images and define areas of inflammation with increased glucose metabolism. In this report the authors present a case of aortoenteric fistula diagnosed by FDG-PET. Early diagnosis led to rapid surgical intervention with graft removal and extraanatomic bypass. These encouraging results warrant larger controlled studies to evaluate the utility of FDG-PET in the diagnosis of prosthetic aortic graft infection.
Aged↗
[Postoperative entero-cutaneous fistula].
Enterocutaneous fistulas of the digestive tract is a major catastrophe of surgical practice. In most cases, they represent serious complications of abdominal surgery. A total of 90% of cases develop of a surgical complication or injury. Despite progress in the management of fistulas, they were traditionally associated with high morbidity and mortality rates. The three major complications of fistulas have been electrolyte disturbance, malnutrition and sepsis. Complications are strongly related to anatomic site of fistula, to biochemical and electrolyte content of discharge, output, and underlying pathology. The ultimate objective in management of patients with enterocutaneous fistulas is fistula closure. In 1964, Chapman proposed management for fistulas in which a set of priorities in treatment was emphasized. Medical treatment is intended to cure (spontaneous closure) or to prepare patients for surgery. It was recognized that adequate nutritional support is an essential part of treatment of enterocutaneous fistulas. Control of sepsis is a priority because sepsis is the most common cause of death. Uncontrolled sepsis should be attacked as early as possible. Although spontaneous closure has increased in most series, it is likely that the majority of patients will require an operation and this should be performed at the proper time.
Digestive System Fistula↗
Intrapelvic complications after total hip arthroplasty failure.
BACKGROUND: Severe total hip arthroplasty failure with central migration of prosthetic components is uncommon. If perforation of the medial acetabular wall occurs, injuries of intrapelvic structures may result. DATA SOURCES: A meta-analysis of the English literature was performed. A human pelvic cadaver was used to demonstrate the proximity of intrapelvic structures to a centrally dislocated cup. RESULTS: Fifty cases of intrapelvic injury were identified. Structures involved most frequently were the external iliac artery and the bladder. The most common types of complication included fistula formation, development of a false aneurysm, and hemorrhage. The human cadaver pelvis demonstrated the proximity of intrapelvic vessels, the bladder, the ureter, the vagina, the deferent duct, the sigmoid colon, the rectum, and the sciatic nerve to an intrapelvically intruded prosthesis. CONCLUSIONS: Failed total hip replacements should be considered to cause damage to pelvic viscera.
Aneurysm, False↗
Factors associated with failure in managing pelvic sepsis after ileal pouch-anal anastomosis (IPAA)--a multivariate analysis.
BACKGROUND: Pelvic sepsis is known to cause a detrimental outcome after ileal pouch-anal anastomosis (IPAA). The aim of this study was to examine potential factors associated with failure in managing pelvic sepsis after IPAA. METHODS: We performed univariate and multivariate logistic regression analysis on 2518 IPAA patients between 1983 and 2005. Failure was defined as pouch failure, the need for a permanent ileostomy, or mortality as a result of sepsis. There were 157 patients (6.2%) with pelvic sepsis after IPAA. These involved anastomotic leak 34% (54/157) and fistula 25% (40/157). There were 5 mortalities related to sepsis. Mean age at surgery was 38.1 +/- 14.4 years and mean follow-up was 5.5 +/- 4.7 years. RESULTS: Pouches were saved in 75.8% patients. Univariate analysis identified early sepsis (P = .040), preoperative steroid use (P = .007), and need for percutaneous drainage (P = .004) as significant factors associated with treatment success. Factors associated with failure were hypertension (P = .026), hand-sewn anastomosis (P = .038), associated fistula (P = .0003), need for transanal drainage (P = .0002), need for laparotomy to control septic complications (P < .0001), delayed ileostomy closure (P = .0003), and need for a new diverting ileostomy (P < .0001). By using multivariate analysis with selected covariates, significant factors associated with failure were associated fistula (P = .0013), need for transanal drainage (P = .003), delayed ileostomy closure (P = .022), need for a new ileostomy diversion (P = .004), and hypertension (P = .039). We developed a predictive scoring system for failure to use in management plans and decision-making for the treatment of septic complications of IPAA. CONCLUSIONS: Pelvic sepsis after IPAA has a significant impact on pouch failure. This predictive model for failure may play an important role in providing risk estimates for successful outcomes.
Abdominal Abscess↗
Endoscopic treatment of postoperative fistulas resistant to conservative management using biological fibrin glue.
BACKGROUND AND STUDY AIMS: Postoperative fistulae occur frequently in standard surgical practice, but there is no general agreement on how to treat them. We summarize here our experience with endoscopic treatment. PATIENTS AND METHODS: Postoperative digestive fistulae resistant to conservative treatment, in 15 patients, are retrospectively reviewed. Our series included two internal fistulas: (one rectovesical, and one high-output pleuroesophagic), and 13 external fistulas (one low-output gastrocutaneous, two low-output esophagocutaneous, seven low-output enterocutaneous, and three high-output enterocutaneous). After failure of conservative treatment, the fistulas were endoscopically located and 2 - 4 ml of reconstituted fibrin glue, Tissucol 2.0 at 37 degrees C, was injected through a catheter. RESULTS: The mean age of the patients was 61.2 years (38 - 86), and 60 % were men. Of the fistulas, 26.6 % were of the high-output type. The mean healing time was 16 days (5 - 40), and a mean of 2.5 sessions per patient were required (1 - 5). Complete sealing of fistulas was achieved in 86.6 % of cases; (87.5 % of the low-output and internal fistulas, and 55 % of the high-output fistulas). After follow-up ranging between 2 months and more than 3 years, only one of the sealed fistulas reopened. No complications were encountered. Overall mortality was 13.3 % (two out of 15), but in only one patient was this related to clinical deterioration because of the persistence of the fistula. CONCLUSIONS: We think that conservative treatment should not be prolonged beyond 14 days and that endoscopic treatment should be performed at that stage. Endoscopic sealing treatment achieves a very high success rate, without complications and at a lower cost. It could probably reduce the hospital stay, and avoid some unnecessary surgical interventions. Appropriate multicenter randomized trials are needed to confirm these results.
Adult↗
Fistula in ano surgery has no impact on pudendal nerve terminal motor latency.
BACKGROUND: Anal fistula surgery is recognized as a major risk factor for anal incontinence. This incontinence is mainly due to surgical sphincter lesions, although a neurogenic mechanism through damage to the pudendal nerve is not excluded. The objective of our study was to evaluate the influence of anal surgery on the anal terminal motor latency of the pudendal nerve (PNTML). MATERIALS AND METHODS: The PNTML values were measured pre- and postoperatively, respectively, in 33 patients (28 men, 5 women) treated for anal suppuration and 34 patients (21 men, 13 women) undergoing pedicular hemorrhoidectomy using the Milligan and Morgan technique. RESULTS: The average age was 49.6 years in the hemorrhoid group and 45 years in the fistula group (p=0.19). There was no difference in the sex ratio between the two groups (p=0.06). In the anal fistula group, the preoperative mean PNTML was 2.42 (+/-0.46) ms on the infected side and 2.40 (+/-0.42) ms on the healthy side, with a significant difference from the control group's preoperative ipsilateral latencies: 2.73 (+/-0.60) ms (p=0.02, p=0.01). The variations in the postoperative PNTML of the fistula group, both on the healthy side (DeltaPNTML=0.06+/-0.42 ms) and on the diseased side (DeltaPNTML=0.03+/-0.40 ms), are comparable with those of the hemorrhoid group (DeltaPNTML=0.01+/-0.48 ms; p=0.63, p=0.84). CONCLUSION: The nervous conduction of the pudendal nerves does not seem to be altered by the presence of an infectious process in the ischiorectal fossa nor by the surgical procedure. However, a more refined electrophysiological study would seem to be necessary to assess the repercussions on the perineal innervation.
Anal Canal↗
Comparison of two ruminoscopy techniques in calves.
Two different techniques were tested in nine calves to describe endoscopically the visible structures of the rumen and the reticulum. Ruminoscopy using an orally introduced flexible endoscope proved to be unsatisfactory, but when the endoscope was introduced through a ruminal fistula in the left flank into the dorsal and ventral ruminal sacs, the blind sacs, ruminal pillars, the atrium of the rumen, the reticulum and the reticular groove could all be displayed effectively. Indentations of the ruminal wall caused by the left kidney, the spleen and the abomasum could be seen with the endoscope as could reticulo-ruminal contractions. The technique allowed visual evaluation of the mucosal surfaces and movement of the rumen, reticulum and reticular groove. The advantages and disadvantages of ruminoscopy in bovine medicine are discussed.
Animals↗
Haemosuccus pancreaticus: a clinical challenge.
BACKGROUND: Haemosuccus pancreaticus is a rare complication of pancreatitis. It is a diagnostic problem for even the most astute clinician and a challenge for the expert endoscopist. We report a 25-year-old male patient who had all the features usually seen in haemosuccus pancreaticus patients: recurrent obscure upper gastrointestinal bleeding, pancreatitis, pseudocyst formation, ductal disruption, fistula and pancreatic ascites. The patient was treated by subtotal pancreatectomy, splenectomy and drainage of the pseudocyst. Although pancreatic duct communication with the surrounding vasculature could not be ascertained, we strongly believe the patient had haemosuccus pancreaticus because, over a follow-up period of 3 years, the patient was not only ascites free, but did not experience any further upper gastrointestinal bleeding. We believe that in evaluating patients with recurrent obscure gastrointestinal bleeding, one should always remember that the pancreas is a part of the gastrointestinal tract and, like other organs, is prone to blood loss.
Adult↗
Compensatory phospholipid digestion is required for cholesterol absorption in pancreatic phospholipase A(2)-deficient mice.
BACKGROUND AND AIMS: Numerous studies have suggested phospholipid inhibition of dietary cholesterol absorption through the gastrointestinal tract. This study addressed the importance of luminal phospholipid hydrolysis in this process. METHODS: The effect of phospholipase inhibition on cholesterol transport from intestinal lumen to the lymphatics was evaluated in lymph fistula rats. Cholesterol and phospholipid absorption efficiency in intact animals was evaluated in control and phospholipase A(2) (PLA2) gene-targeted mice. RESULTS: The PLA2 inhibitor FPL 67047XX retarded cholesterol absorption in a lymph fistula rat model. Under basal chow-fed dietary conditions, cholesterol absorption efficiency from a single bolus meal, and plasma lipid levels, were similar among PLA2+/+, PLA2+/-, and PLA2-/- mice. Interestingly, the nonhydrolyzable phospholipid dioleoyl ether phosphatidylcholine suppressed cholesterol absorption by 10% to 18% in mice without regard to their PLA2 genotype. When 1-palmitoyl-2-[(14)C]oleoyl-phosphatidylcholine was used as the substrate, the radiolabeled phospholipid was found to be hydrolyzed and absorbed with equal efficiency in PLA2+/+, PLA2+/-, and PLA2-/- mice. CONCLUSIONS: These results suggested that although phospholipid digestion in the intestinal lumen is a prerequisite for efficient cholesterol absorption, additional enzyme(s) can compensate for pancreatic PLA2 in catalyzing phospholipid digestion and facilitating cholesterol absorption in PLA2 knockout mice.
Animals↗
Cholecystoduodenoplasty for high-output duodenal fistula.
External duodenal fistulae from sutured duodenal ulcer perforation sites are difficult to manage and most patients succumb to septicemia and undernutrition. This is due to failure of closure of the perforation site in the duodenum. Most techniques described in the past to facilitate closure have failed to give satisfactory results. We have devised a new procedure where the duodenal ulcer perforation is closed by mobilizing the gall bladder. A hole is made in the fundus of the gall bladder and it is anastomosed to the freshened edges of the duodenal opening. We have treated six patients by this technique. In five patients the leak was satisfactorily sealed. Three patients died - one due to persistent leak and two due to jejunostomy leak.
Anastomosis, Surgical↗
Long-term oral tacrolimus therapy in refractory to infliximab fistulizing Crohn's disease: a pilot study.
AIMS: To evaluate efficacy and safety of oral tacrolimus in cases of fistulizing Crohn's disease (FCD), which is refractory to conventional therapy including infliximab. METHODS: Patients with fistulas, previously and unsuccessfully treated with all conventional therapy (i.e., antibiotics, azathioprine, or 6-mercaptopurine and infliximab), were enrolled in a prospective, uncontrolled, open-label study of long-term treatment with oral tacrolimus (0.05 mg/kg every 12 h). The evaluation of the clinical response was complemented by use of the perianal Crohn's disease activity index (PCDAI) and magnetic resonance imaging-based score (MRS) with determined periodicity. RESULTS: Ten patients were included in the study (enterocutaneous fistula, 3 patients; perianal fistula, 4 patients; rectovaginal fistula, 3 patients) with 6 to 24 months of follow-up. Five patients were steroid-dependent, and 4 patients needed maintenance treatment with immunosuppressant agents. Four patients (40%) achieved complete clinical responses, which were verified by PCDAI and MRS. Five patients (50%) achieved partial responses (i.e., important decreases in fistula drainage, size, discomfort, and PCDAI/MRS values). Decreases in both the PCDAI and MRS were statistically significant (P < 0.05). All steroid-dependent patients stopped therapy with prednisone, and concomitant immunosuppressive therapy was tapered. The response was maintained, and no new flare-up of the disease was observed. Only mild adverse events were detected (1 patient withdrew from treatment due to headache), and no case of nephrotoxicity or diabetes was detected. One patient had received no benefit from therapy after 6 months. CONCLUSIONS: Oral tacrolimus could be an effective and safe treatment for patients with FCD, even if there has been no response to infliximab treatment. Randomized studies are needed to compare oral tacrolimus with infliximab in terms of efficacy, safety, and costs.
Administration, Oral↗
Indications and operative techniques for combined aortoesophageal resection.
Combined aortoesophageal resection was performed in 8 patients, including 7 with esophageal carcinoma and 1 with aortoesophageal fistula. Aortic resection procedures included segmental resection with permanent aorto-aortic bypass (1 case), segmental resection with graft interposition (1 case), semicircumferential resection with patch aortoplasty (3 cases), wedge resection with lateral aortorrhaphy (1 case), and resection of adventitia (2 cases). Protective methods during aortic cross-clamping included one aorto-aortic permanent bypass, one subclavian-aortic bypass, and three axillo-femoral bypass. Postoperative complications include mediastinal abscess, paresis, arrythmia, and pneumonia. Five patients with esophageal carcinoma died within 6 postoperative months. In 4 of these 5 nonsurvivors, metastasis to distant organs including the liver, bone and peritoneal cavity were found at the time of death or autopsy. Those early recurrence cases were characterized by skip lesions and extensive lymph node metastasis with extranodal invasion. The clinical benefit of aortoesophageal resection will be attained by careful preoperative evaluation for case selection and a sufficient protective method for aortic cross-clamping.
Aged↗
Evolution of surgical treatment for pharyngeal pouch.
BACKGROUND: The development of endoscopic techniques, particularly endoscopic stapling, has led to a re-evaluation of the treatment of pharyngeal pouch. The pathophysiology and treatment of the condition is reviewed. METHODS: An electronic literature search was undertaken on the pathophysiology, history and surgery of pharyngeal pouch (Zenker's diverticulum). These last two terms were used to the search the Cochrane, Medline and Embase databases (from 1966 to date) and the bibliographies of extracted articles. RESULTS AND CONCLUSION: With recognition of the central role of the cricopharyngeus muscle in the pathogenesis of pouch formation, the emphasis on treatment has shifted from diverticulectomy to cricopharyngeal myotomy. Minimally invasive techniques have become established since the advent of endoscopic stapling devices. Although randomized controlled data are lacking, the endoscopic approach appears to offer advantages in terms of a shorter duration of anaesthesia, more rapid resumption of oral intake, shorter hospital stay and quicker recovery. It is associated with excellent success rates and minimal morbidity.
Digestive System Fistula↗
Occult intrabiliary rupture of hydatid cysts in the liver.
The aim of this study was to investigate the effects of various surgical modalities directed at the cavity of hydatid cysts in patients with occult intrabiliary rupture. In this respect, 324 patients with hydatid cyst of the liver operated on during 1983-2003 were analyzed; among them, 39 patients with occult intrabiliary rupture were included in the study. Clinical symptomatology, physical examination, laboratory findings, results of imaging studies, the localization and size of the cyst, and operative findings were reviewed. Twelve patients had complications, and there was no mortality. The most common complication was bile fistula. The average postoperative hospital stay was 7.0 +/- 3.8 days for patients with omentoplasty and 6.0 +/- 2.5 days for those who underwent cavitary drainage. For patients who do not have bile-stained cystic fluid, the utilization of scolicidal agents is appropriate. Although the opening of the duct is sutured when it is identified, the risk of biliary fistula is not clearly correlated with this approach. In such cases, omentoplasty provides a good alternative to cavitary drainage.
Adolescent↗
Congenital intrahepatic portosystemic shunt.
The authors report a congenital intrahepatic portosystemic shunt detected by angiography in a young patient with acute onset of hyperammoniemia and hepatic encephalopathy.
Adolescent↗
Double common bile duct with ectopic drainage into the stomach. Case report and review of the literature.
A rare abnormal biliary tract consisting in a double common bile duct with an ectopic biliary tree draining into the stomach is described. This congenital anomaly, associated with lithiasis in the ectopic duct, was detected for the first time on MR-cholangiopancreatography. Only 23 cases of abnormal biliary drainage into the stomach have been reported in the literature. Embryogenesis and potential risks, such as lithiasis in the ectopic duct and the development of gastric carcinoma, are discussed.
Aged↗
Results after endoscopic treatment of postoperative upper gastrointestinal fistulas and leaks using combined Vicryl plug and fibrin glue.
BACKGROUND: The incidence of clinically relevant anastomotic leaks after upper gastrointestinal surgery is approximately 4% to 20%, and the associated mortality is up to 80%. Depending on the clinical presentation, the treatment options include surgery, conservative treatment with or without external drainage or endoscopic treatment. METHODS: This report presents nine cases of anastomotic leaks or fistulae after surgery for upper gastrointestinal cancers that were treated by insertion of a Vicryl plug and sealing with fibrin glue. Under sedation, all nine patients underwent endoscopic lavage of the cavity at the site of anastomotic leakage. The entrance to the cavity then was filled with Vicryl mesh and sealed off with fibrin glue. After the procedure, the patients underwent endoscopy and a water-soluble contrast study for assessment of the result. RESULTS: Seven of the nine patients had complete healing of the anastomotic leak or fistula after one to two endoscopic treatments. In one case, the treatment failed immediately because of a large and direct tracheoesophageal fistula. Another patient experienced recurrent intrathoracic abscesses after initial technical success. CONCLUSIONS: Postoperative upper gastrointestinal fistulas or anastomotic leaks can be managed successfully with little morbidity by means of endoscopic insertion of Vicryl mesh with fibrin glue, thereby avoiding repetitive major surgery and its associated risks.
Adult↗