Colonic Fistula Research Articles

Pringle maneuver and risk of colonic leakage in combined colorectal and hepatic resections: myth or reality?

Background: The aim of the present study was to compare the outcome of combined colorectal and hepatic resections with and without pringle maneuver and to analyse the possible effect of liver-related factors on colonic anastomosis leakage. Methods: 250 Combined colorectal and hepatic resections performed in two european referral centers were stratified according to intraoperative use of Pringle maneuver. 71 procedures with Pringle (Pringle group) were matched with 71 procedures without pringle (NoPringle group) using propensity scores in a 1:1 ratio. Results: The two groups resulted similar in terms of preoperative characteristics (distibution of rectal tumors and neoadjuvant treatments). Intraoperative blood loss was reduced in the Pringle Group (150 ±100 mL) compared with the noPringle group(250 ± 200 mL, p=0.05), while postoperative morbidity (29.5% and 32.4% respectively) and incidence (9.9% in both groups) and severity of colonic fistula. At uni- and multivariate analysis for liver-related factors potentially affecting risk of colonic fistula, a preoperative albumin level < 3.5 g/dL resulted associated with leakage. Extension of liver resection, Pringle maneuver and length of Pringle maneuver did not show a significant correlation with anastomotic leakage. Conclusion: The use of Pringle maneuver in the setting of combined hepatic and colorectal resections allows to maintain a potential advantage in terms of reduction of intraoperative bleeding, without negatively affecting the risk of anastomotic leakage. On the contrary, an impaired synthesis of protein (resulting in a low preoperative level of albumin) seems to affect the risk of leakage, as a result of an ineffective wounds healing.

Pancreatic colonic fistulae, an incidental finding in a patient with newly diagnosed chronic pancreatitis

Pancreatic colonic fistulae, an incidental finding in a patient with newly diagnosed chronic pancreatitis

The surgical treatment of acute and severe diversion colitis mimicking ulcerative colitis: a case report

BackgroundDiversion colitis (DC) is characterized by nonspecific inflammation in the remaining colon or rectum, and loss of the fecal stream plays a major role in the disease’s development. Although the majority of patients are asymptomatic, medical and/or surgical treatment is required for those who are symptomatic. There is a particular interest on how to manage patients with acute and severe clinical presentations, but the pathogenesis is not fully understood. We report the rare case of a man with acute and severe DC mimicking ulcerative colitis (UC) with extra-intestinal manifestations that was successfully managed with surgical treatment.Case presentationA 68-year-old man with a history of laparoscopic intersphincteric resection of the rectum with diverting loop ileostomy for lower rectal cancer suffered from anastomotic stenosis requiring repeated endoscopic dilatation. His loop stoma was not reversed because these treatments were unsuccessful. He denied having a history of inflammatory bowel disease. Twelve years postoperatively, he developed a perineal abscess requiring drainage. Subsequently, he developed a high-grade fever, bloody discharge per anus, and skin ulcers in the right ankle and around the stoma. Because culture tests were negative for bacteria, it was deemed that his acute illness reflected an inflammatory response rather than an infectious disease. Colonoscopy revealed anastomotic stenosis, a colonic fistula, and mucosa that hemorrhaged easily, with lacerations. A pathological examination with biopsy revealed inflammatory infiltration without malignancy. After reviewing the patient’s clinical episodes and discussing the case with physicians in multiple specialties, we performed total colectomy with end ileostomy in accordance with the abdominoperineal resection. The postoperative course was uneventful. A resected specimen showed atrophic mucosa with the disappearance of haustra in the distal colon, as well as edematous and dilated mucosa in the proximal colon. The pathological diagnosis was suggestive of UC, including erosion and ulceration in edematous wall, crypt abscess, and inflammatory infiltration into the mucosa. The skin ulcers in the right ankle and around the stoma healed over time.ConclusionsDC can eventuate in a long-term period after fecal diversion surgery, possibly with extra-intestinal manifestations mimicking UC. Surgical treatment seems feasible for patients with acute and severe DC.

Perforated Meckel's Diverticulitis Mimicking Penetrating Crohn's Disease

A 35-year-old previously healthy man was transferred to our hospital for presumed new diagnosis of penetrating Crohn's disease (CD). Magnetic resonance enterography showed long-segment ileal inflammation and duodenal to transverse colon fistula with small, nondrainable abscesses (Figure A) consistent with CD. Upper and lower endoscopy with ileal intubation were normal. After clinical improvement, he was discharged on a corticosteroid taper and antibiotics with plans for additional small bowel evaluation.

A Challenging Case of Retroperitoneal Abscess in a Post-Partum Crohn’s Disease Patient

Patient: Female, 29Final Diagnosis: Retroperitoneal abscessSymptoms: Flank bruising • flank painMedication: —Clinical Procedure: Incision • drainage • debridement of the necrotizing soft-tissue infectionSpecialty: Infectious DiseasesObjective:Unusual clinical courseBackground:Crohn’s disease (CD) is an inflammatory bowel disease affecting approximately 1 in 3000 people in the United States. Since the inflammation of CD is transmural, patients are at risk for fistula and abscess formation. Retroperitoneal abscesses are one type of which physicians must be aware.Case Report:We present the case of a 29-year-old woman with CD who complained of right hip and flank pain that began when she was 6-months pregnant. After delivery, she continued to complain of severe right flank pain and was admitted to the hospital 1 month later. CT scan imaging revealed a complicated retroperitoneal and right flank abscess, possibly due to a colonic intramural fistula. She developed severe acute necrotizing soft-tissue infection requiring 13 days of intensive care. She required debridement of the necrotizing infection of the right flank, drainage of the abscess, and washout for intraperitoneal sepsis. The patient tolerated the procedures well and was discharged 1 month later.Conclusions:Given that the clinical manifestation of retroperitoneal fistula with abscess is insidious and its formation is less common than intraperitoneal abscesses, we hope healthcare providers learn from this case to avoid morbidity and mortality. When presented with a pregnant CD patient complaining of nonspecific abdominal symptoms, providers should consider fistulization and/or abscess formation. The option to evaluate pregnant patients using noninvasive methods, such as ultrasound or low-dose CT scan, can decrease radiation exposure to the fetus and prevent delays in diagnosis and treatment.

Can Patients with Appendicitis in Pregnancy be Operated in Secondary Hospital: A retrospective Study

Appendicitis is the most common non-obstetric cause of acute abdomen in pregnancy. Diagnosis of appendicitis becomes difficult with the change of appendiceal position during pregnancy. Late diagnosis and treatment increase the likelihood of developing perforation. In this study, we aimed to evaluate perioperative outcomes of appendicitis in pregnant patients in secondary hospitals in the light of the literature. 29 pregnant women who performed appendectomy between April 2012 and July 2017 were included in the study. Patients were evaluated according to age, gestational age, white blood cell count, percentage of neutrophil count, C-reactive protein level, ultrasonographic findings, pathologic results, duration of hospitalization and complications. Out of the 29 pregnant patients, 9 (31.0%) patients had surgery during the first trimester, 13 (44.8%) during the second trimester and 7 (24.2%) during the third trimester. Median white blood cell count was 12870 K/mm3 (min-max;7170-25210). Negative laparotomy rate was %31.0. Median duration of hospitalization was 3.24 days (2-7). Morbidity was observed in 2 (6.9%) of 29 patients. Intra-abdominal abscess was observed in one patient and colonic fistula was observed in one patient. Our results demonstrated that appendectomy and follow-up of pregnant patients with acute appendicitis can be performed at secondary hospitals.

Laparoscopic combined with percutaneous nephroscopic necrosectomy for peripancreatic abscesses: a report of 8 cases

Objective To study the effect of combined laparoscopic and percutaneous nephroscopic necrosectomy in the treatment of peripancreatic abscesses. Methods The clinical data of 8 patients with peripancreatic abscesses treated by combined laparoscopic and percutaneous nephroscopic necrosectomy in our hospital from June 2015 to June 2017 were retrospectively analyzed. Results 8 patients were treated with percutaneous puncture and drainage under Ultrasonic / Computed Tomography guidance. Combined laparoscopic and percutaneous nephroscopic necrosectomy was then carried out. Two patients underwent percutaneous nephroscopic surgery twice and laparoscopic surgery once, and 3 patients underwent percutaneous nephroscopic surgery thrice, and 3 patients underwent percutaneous nephroscopic surgery 4 times and laparoscopic surgery once. One patient after percutaneous nephroscopic necrosectomy was complicated with sinus tract hemorrhage, which was treated by haemostasis through a small incision. Two patients who developed postoperative colonic fistula were treated successfully by conservative treatment. The average length of hospital stay was 80 d (60~153 d), and there was no death. Conclusion Combined laparoscopic and percutaneous nephroscopic necrosectomy was a minimally invasive and efficacious method to treat peripancreatic abscesses. Key words: Pancreas abscess; Pancreatitis, infected necrotizing; Laparoscopy; Percutaneous nephroscopy; Necrosectomy

Cholecysto-Colic Fistula: Case Report

Chronic diarrhea as a result of colonic fistulas -two case reports with different origin. When it comes to chronic diarrhea symptom, the first thing one thinks of is never a surgical cause, but an infectious disease. The aim of this paper is to show 2 different cases of chronic diarrhea, resulting from benign surgical causes - colonic fistula. The first case is a result of cholecystocolic fistula, while the second is the result of gastrojejunocolic fistula. Colonic fistulas originate from different causes: malignancy, NSAID, diverticulosis of the colon, cholecystitis, pancreatitis, lymphoma, or after radiation therapy. They can also result from a trauma, which can be post-surgical.

Endoscopic management of a colonic fistula communicating with a walled-off pancreatic necrosis

Endoscopic management of a colonic fistula communicating with a walled-off pancreatic necrosis

An innovative method for placing a double-lumen irrigation-suction tube in the management of abdominal infection

Rationale:Currently, the use of double-lumen irrigation-suction tube for drainage has become increasingly more common. However, the insertion process is complex, and the position of the double cannula placed in this manner is not accurate. We developed a method for placing the drainage tube and use it in the treatment of an abdominal infection.Patient concerns:A 51-year-old man with an abdominal infection due to colonic anastomotic fistula was admitted. Routine laboratory tests revealed an elevated white blood cell count (17 × 109/L) and C-reactive protein level (78 mg/L). Computed tomography (CT) revealed that the peritoneal cavity was filled with fluid.Diagnoses:The patient was diagnosed with colonic anastomosis fistula by gastrointestinal radiography. Abdominal infection was diagnosed based on CT scan, inflammatory markers, and patient signs and symptoms.Interventions:Two punctures were performed. After skin expansion, the source of infection was drained with a suction catheter (diameter = 1.0 cm) under continuous negative pressure of 150 to 200 millibars, along with continuous saline irrigation at 300 mL/h.Outcomes:Pus in the abdomen drained completely. The abdominal infection was controlled. There were no adverse events.Lessons:Abdominal infection in fistulas is a fatal disease. The main therapeutic target is full drainage at an early stage. Precise positioning of the tube, continuous negative pressure irrigation and drainage are key points in the treatment.

Colonic Fistula Secondary to Acute Pancreatitis: A Case Report

Colonic Fistula Secondary to Acute Pancreatitis: A Case Report

A Case of Colonic Bladder Fistula Due to Sigmoid Colon Diverticulitis Treated Laparoscopically

A Case of Colonic Bladder Fistula Due to Sigmoid Colon Diverticulitis Treated Laparoscopically

Surgical management in acute diverticulitis and its association with multi-detector CT, modified Hinchey classification, and clinical parameters.

To assess whether CT findings, clinical parameters, and modified Hinchey classification are predictive of management outcomes of patients with acute diverticulitis. Data were accrued between January 2014 and December 2015. A total of 301 adult subjects were identified from radiology reports, of which six who did not met the inclusion criteria were excluded, thus yielding 295 subjects. Subjects were 43.1% (n=127) male and 56.9% female (n=168), with mean age 51.9years (range18-90). Two independent abdominal radiologists reviewed all scans; imaging features and a modified Hinchey classification were scored. Descriptive statistics compared the relationships between imaging findings, clinical parametersobtained from medical record review, and modified Hinchey classification with management outcomes. CT findings associated with surgical management include the presence of a pericolonic fluid collection (36.8% vs. 8.2%, P=0.0001), colonic fistula (13.2% vs. 0.4%, P=0.0002), extraluminal air (26.4% vs. 9.3%, P=0.0052), bowel obstruction (5.2% vs. 0.0%, P=0.0162), and a modified Hinchey score of Ib or higher (55.3% vs. 11.7%, P=0.0001). Slightly lower systolic blood pressure was also associated with operative management (137.2mmHg vs. 128.2mmHg, P=0.0220). Specific CT imaging features and modified Hinchey classification are associated with subsequent surgical management in patients with acute diverticulitis.

Liver Hydatid Cyst Complicated by Biliary and Colonic Fistula Diagnosed after Intra-Operative Cholangiography

Abstract Background: Hydatid disease is a worldwide zoonosis and is localized in the liver in most cases. Biliary rupture and infection are the most common complications of hydatid liver. Simultane...

Treatment of Walled-off Pancreatic Necrosis by Percutaneous Endoscopic Necrosectomy

Walled-off pancreatic necrosis (WOPN) consists of a mature collection of pancreatic necrotic tissue within a well-defined inflammatory wall. Treatment involves drainage and debridement of the necrotic material. Modalities such as laparoscopic, endoscopic, and video-assisted retroperitoneal debridement are effective, and have less morbidity than open surgery. Percutaneous endoscopic necrosectomy (PEN) is a novel technique that allows the operator to use conventional endoscopes to perform necrosectomy via a percutaneous tract in patients with WOPN that is difficult to access via the stomach or duodenum. A 44-year old male with newly diagnosed diabetes mellitus presented with severe abdominal pain and sepsis secondary to a peripancreatic fluid collection that developed after an episode of acute pancreatitis. On arrival, his vitals were: Temp 100.4 F, BP 100/63 mm Hg, HR 129 beats/min, RR 20 breaths/min, and SPO2 96% room air. Abdominal examination revealed mild distension and severe epigastric tenderness. A percutaneous drain was placed via the left flank into the fluid collection at another facility. However, the collection persisted and grew E. Coli and K. Pneumoniae. Endoscopic ultrasound showed a debris-filled cavity abutting the pancreatic tail without close approximation to the gastric wall. Following upsizing of the percutaneous drain, three sessions of PEN were performed via the drain tract. Ongoing drainage was found to originate from a colonic fistula and pancreatic duct leak, which were treated with a diverting loop colostomy and endoscopic retrograde cholangiopancreatogram (ERCP) with pancreatic duct stent placement, respectively. The patient's condition improved with and resolution of the duct leak, confirmed on repeat ERCP performed two months later. His percutaneous drainage eventually stopped and the external drain was removed. PEN is a safe and effective minimally invasive technique that can be used to treat WOPN. It may be the procedure of choice in instances where necrosis cannot be accessed through the stomach or duodenum. Recent studies have shown that PEN has superior safety profile compared to the existing endoscopic (e.g. transgastric endoscopic necrosectomy) or surgical interventions. Additionally, percutaneous access along a predefined tract avoids inherent complexities of the transluminal approach. This novel technique may also be utilized for other intra-abdominal fluid collection accessible to interventional radiologists.

Clinical study of enterocutaneous fistula

Background: An enterocutaneous fistulae (ECF) may be challenging to manage due to the large volume of fluid losses, that may result in severe dehydration, electrolyte imbalances, malnutrition and sepsis. It is imperative that this group of patients receive adequate nutrition, as malnutrition and sepsis are the leading cause of death.Methods: This descriptive study was conducted prospectively in the Department of Surgery between September 2004 and August 2010. Patients whom develop ECF after surgery were included in the study while patients with esophageal, biliary, pancreatic, and perianal fistulas were excluded. The description of fistula included cause, anatomical location, fistula output, complications, and outcome. Fistula output was quantified by direct measurement, in the presence of drain or by calculating number of dressing pads soaked per day. To examine the statistical significance of association between attributes, Chi-square test and Fisher's exact test were used. A probability value of less than 5% (P &lt; 0.05) was considered significant.Results: A total of 42 patients were included in the study, of which 23 were males and 19 were females and the male:female ratio was 1.2:1. Most patients with ECF were aged 41-50 (mean age, 44.23±2.72). Of the 42 patients, 9 patients had colonic fistula and the remaining had small intestinal fistula; 16 ileal, 5 duodenal, and 12 jejunal. There were 22 patients with high-output fistula as compared to 20 patients with low output fistula. Mortality was significantly higher in patients with males, age &gt;60 years, high-output fistula, mesenteric ischemia as underlying pathology, serum albumin &lt;2.5g/dl and re-surgery.Conclusions: Early diagnosis and stabilization form key aspects of management of ECF as most patients are managed conservatively. Prompt nutritional supplementation alters the outcome of this disease. High output fistulae required mostly surgical management and had high morbidity and mortality.

A prospective study of feasibility and short term outcome of stoma reversal under local anaesthesia

Background: Stoma fashioning (ileostomy and colostomy) are very important and established procedures for deviation of bowel contents to procure the distal anostomosis. It is a very common procedure in cases of bowel obstruction, perforation, inflammatory bowel disease and large bowel disorders like Ca colon and Ca rectum, colonic fistulas, trauma to colon and rectum. Stoma reversal is a routine procedure but is usually performed using general or regional anaesthesia but large number of patient list for stoma reversal under general or regional anaesthesia, led to unnecessary delay in stoma reversal due to paucity of anaesthesia. Local anaesthesia has thus proved useful to handle a large load of stoma reversal, so we investigated feasibility of performing stoma reversal using local anaesthetic agent.Methods: Total 54 patients underwent for stoma reversal under local anaesthesia, admitted to Department of General Surgery, Nehru Hospital, B. R. D. Medical College, Gorakhpur, Uttar Pradesh, India.Results: Reversal of stoma could be comfortably done under safe dose of local anaesthesia, most of the patients remain comfortable intraoperatively, 4 out of 54 patients had systemic complications like vomiting and bradycardia and 2 had associated bowel injury. only 2 patients had minor anostomotic leak and 1 had developed fecal fistula while rest had normal intact anostomosis. Only 2 patients had reported moderate pain and 1 had mild pain according to visual analog scale and in 42 out of 54 patients had normal wound healing while 5 had minor erythema, 6 had seroma formation and 1 had complain of pus discharge.Conclusions: Reversal of STOMA can be performed safely and comfortably under local anaesthesia. Post op short term outcome and complications are comparable to that done under general or regional anaesthesia.

ADVL1522: A phase 2 study of IMGN901 (lorvotuzumab mertansine; IND# 126953, NSC# 783609) in children with relapsed or refractory Wilms tumor, rhabdomyosarcoma, neuroblastoma, pleuropulmonary blastoma, malignant peripheral nerve sheath tumor (MPNST), and synovial sarcoma: A Children's Oncology Group study.

10537 Background: Lorvotuzumab mertansine (IMGN901; LM) is an antibody-drug conjugate, linking anti-mitotic agent (DM1) to an anti-CD56 antibody. Preclinical data show effects in Wilms tumor (WT), rhabdomyosarcoma (RMS), and neuroblastoma (NBL). Synovial sarcoma (SS), MPNST and pleuropulmonary blastoma (PPB) also express CD56. A phase 2 trial assessing the efficacy and tolerability of LM administered at the adult recommended phase 2 dose (RP2D) was conducted in children with relapsed tumors. Methods: LM (110 mg/m2/dose) was administered IV on days (d) 1 and 8 of 21 d cycles, with dexamethasone pre-medication. The tolerability of LM was assessed in 6 patients prior to trial activation group-wide. Dose limiting toxicity (DLT) was assessed using CTCAE. Response was assessed by RECIST. Pharmacokinetics (PK) were obtained during cycle 1. Peripheral blood CD56-positive cells were measured d1 and d8 pre-dose. Tumor CD56 expression by immunohistochemistry in archival tissue was scored (0-3+). Results: Sixty-two patients were enrolled. The median (range) age was 14.3 y (2.8–29.9); 35 were male. Diagnoses included WT (17), RMS (17), NBL (12), SS (10), MPNST (5) and PPB (1). One patient was ineligible due to lack of measurable disease. Of 61 eligible patients, 47 were evaluable for toxicity, 50 for response, 50 for tumor CD56 expression; and 18 consented to optional PK. Five patients experienced 9 DLTs: hyperglycemia (1), colonic fistula (1) with perforation (1), nausea (1) with vomiting (1), increased ALT (2 in cycle 1; 1 in cycle 2 with increased AST (1)). Non-dose limiting toxicities (Grade ≥3) attributed to LM included lymphopenia, anemia, vomiting, dehydration, hypokalemia, hyperuricemia, hypophosphatemia. Mean DM1 Cmax, t1/2 and AUC0-∞values were 922 ng/ml, 33 h and 27400 ng/ml*h, respectively. Tumor CD56 expression was 0 (8%), 1+(4%), 2+(12%), 3+(76%). LM and CD56 antibody PK, and response, will be reported. Conclusions: LM (110 mg/m2) is tolerated in children at the adult RP2D. Clinical trial information: NCT 02452554.

Minimally invasive treatment of walled-off pancreatic necrosis complicated by colonic fistula

Objective: Walled-off pancreatic necrosis (WOPN) is a life-threatening complication of acute pancreatitis, occurring more than 4–6 weeks after the initial attack. WOPN can lead to serious additional complications such as sepsis, hemorrhage, or gastrointestinal and pancreatic fistula formation. Our video presents a case of WOPN complicated by colonic fistula managed surgically via laparoscopic cyst-gastrostomy followed by video-assisted percutaneous pancreatic necrosectomy. A 54 year old man was admitted to an outside hospital with alcohol-induced acute pancreatitis and subsequently developed a peri-pancreatic fluid collection. His symptoms resolved without additional intervention and he was able to resume a regular diet. Two months later the patient was admitted to our institution with sudden onset of severe abdominal pain and sepsis. Imaging studies revealed a 25 cm area of gas-containing WOPN suggestive of infected contents. A laparoscopic cyst-gastrostomy was performed evacuating a large amount of stool and solid necrotic debris confirming fistulization to the left colon. Seven days later, residual necrosis was removed via video-assisted percutaneous retroperitoneal approach utilizing a 12 mm trocar. The patient had a favorable clinical evolution and was discharged home 15 days later on enteral nutrition, having resumed normal bowel function, and with scant output from an indwelling drain. Follow-up imaging confirmed near-complete resolution of the WOPN. Our case report illustrates the effectiveness and safety of minimally invasive approaches in the management of WOPN complicated by colonic fistula, without the need for stool diversion and open procedures.

Cholecystocolic fistula from colonic diverticular disease with concomitant choledocholithiasis: A case report

We present a 79 year-old female who consulted for abdominal pain. There was evidence of sigmoid diverticulitis with colonic obstruction and biliary-enteric fistula formation, on the imaging. The patient underwent a Hartmann’s Procedure, resection of cholecystocolic fistula, and intraoperative choledochoscopy with common bile duct stone extraction. The pathophysiology and management of cholecystocolic fistula are discussed.