Diverticular Fistula Research Articles

ОПЫТ ЛЕЧЕНИЯ ПАЦИЕНТОВ СО СВИЩАМИ ОБОДОЧНОЙ КИШКИ ДИВЕРТИКУЛЯРНОГО ПРОИСХОЖДЕНИЯ

Abstract. Introduction. In the 21st century, a massive increase was noted in the incidence of diverticular disease (DD) by more than 10 times with an increase in the frequency of its complications ranging from 5 to 25%. According to the literature, the colon fistulation frequency is 5-30%, over a half of such formations being colovesical fistulas. The problem of surgical approaches to the purulent-inflammatory complications of DD is far from being resolved. Despite the fact that diverticular disease is a benign pathology, inflammatory process often creates serious technical difficulties in surgery due to the violation of the anatomical relationship of the intestine with the surrounding organs, while surgeries often affect several organs with a high infection risk. Aim. Analysis of the results of the treatment of patients with diverticular colon fistulas in a specialized department of a multidisciplinary hospital. Materials and Methods. Treatment outcomes were analyzed retrospectively in 347 patients with diverticular colon disease complications for the period from 2013 to 2022. The study included 17 patients with diverticular fistulas: 14 (82.4%) patients with internal (intestinal-urinary (13) and intestinal-vaginal (1)) fistulas and 3 (17.6%) with external ones. Results and Discussion. The therapeutic and diagnostic algorithm for diverticular fistulas required a wide range of diagnostic methods and a multidisciplinary approach. Surgery remains the single treatment option for this pathology. The choice of the surgical procedure depended on the inflammatory process severity, its spread to the surrounding abdominal organs, and the largest diverticula accumulation in the gut. In the group of patients with intestinal-urinary fistulas, the resection was not limited to the removal of the colon segment only. In 9 (52.9%) cases, it was expanded to the anterior rectum resection due to the inflammation transition to its upper ampullary region. We are supporters of the one-stage surgical procedures with forming the primary anastomosis in patients with diverticular fistulas. We give preference to the Sigal-Ramazanov invagination anastomosis that allows avoiding the anastomosis due to creating a duplicate of the intestinal wall hiding the anastomosis zone. The paper identifies probable predictors of complicating diverticular disease with fistulation. Conclusions. Choosing the optimal treatment option for patients with diverticular disease complications is a difficult problem. It is better to operate on them in the coloproctology departments of multidisciplinary hospitals with the established good interaction among the members of a multidisciplinary team.

Value of computed tomography and abdominal ultrasound for chronic inflammatory complications of diverticular disease

Aim: to evaluate the diagnostic value of computed tomography (CT) and abdominal ultrasound (US) for chronic inflammatory complications in patients with diverticular disease (DD).Patients and Methods: the prospective cohort study included 50 patients with complicated DD. All patients underwent preoperative abdominal CT with intravenous contrast and abdominal US, with further elective bowel resection. The results of CT and ultrasound were compared with morphology of the removed specimens.Results: the sensitivity and specificity for chronic diverticulitis was 66.7% and 95.7% for CT and 100.0% and 95.7% for US. For chronic pericolic abdominal mass it was 94.8% and 90.9% for CT, 94.8% and 100.0% for US; for abdominal abscesses/cavities it was 87.5% and 96.2% for CT and 91.6% and 100.0% for US; for diverticular fistulas it was 87.5% and 100.0% for CT and 87.5% and 100.0% for US. No significant differences were obtained between two diagnostic modalities. A high level of consistency (κ-coefficient 0.71) of CT and US for the diagnosis of inflammatory complications of DD was found. Conclusion: CT and US have a similar high diagnostic value for chronic inflammatory complications of DD. Each of them can be used as a single diagnostic modality or both depending on the clinical case.

Right-sided colopleural fistula secondary to diverticular disease: a case report

BackgroundColopleural fistulas are mostly left-sided and related to trauma, Crohn’s disease, or gastrointestinal malignancy. However, a diverticular fistula between the colon and right pleural space has not been reported and is rare considering the liver forms a natural anatomical barrier on this side. Colopleural fistulas often present with respiratory symptoms ranging from mild cough and dyspnea to sepsis from empyema caused by the leakage of gastrointestinal content into the pleural space. Although colopleural fistulas are rare, maintaining low suspicion is pivotal for timely investigation and appropriate surgical planning, particularly in the context of previous intra-abdominal infections or trauma.Case presentationA 67-year-old Chinese male presenting with prolonged respiratory symptoms was found to have a right-sided colopleural fistula confirmed by computed tomography imaging and a colonoscopy. It was addressed surgically after multidisciplinary consensus was reached, with a right hemicolectomy and repair of the diaphragmatic defect. The patient recovered remarkably well with resolution of respiratory symptoms.ConclusionAppropriate work-up of a suspected colopleural fistula with radiological and endoscopic investigations to determine anatomy and etiology is crucial. Most cases will require surgical management, and involvement of the respiratory and cardiothoracic teams is important to optimize lung function preoperatively and plan for possible chest complications.

S2240 Uncommon Presentation of Acute Diverticulitis Complicated by Colovesical Fistula

Introduction: Acute Diverticulitis primarily occurs in elderly men, with incidence increasing with increasing age. However, the incidence of diverticulitis in men aged 18 to 44 years is increasing. The most common presenting symptoms of acute diverticulitis are Abdominal Pain, Fever, Chills, Constipation, Diarrhea, and Nausea. Complications include abscess, obstruction, perforation, and fistula formation. Here we present an unusual case of a young male, who presented to our hospital with symptoms of UTI and was subsequently found to have a colovesical fistula secondary to acute diverticulitis. Treating physicians should be aware of the rare presentation of acute diverticulitis and should have a high index of suspicion when treating similar cases. Case Description/Methods: A 31-year-old Hispanic Male with a history of colonic diverticulosis and one episode of diverticulitis 4 years ago was presented to the hospital with the chief complaint of dysuria, increased urinary frequency, and urgency. His Vitals and Laboratory findings on presentation are shown in the table below. The physical exam did not show abdominal tenderness. He was clinically diagnosed with UTI and was started on appropriate antibiotics. He continued to have fever spikes and also developed passage of brown particles along with the passage of air in his urine. During his hospital stay, he did not have any abdominal pain, nausea, vomiting, diarrhea, or constipation. Based on the above history, an abdominal CT with contrast was obtained that showed acute diverticulitis of the sigmoid colon with colovesical fistula. The patient underwent robotic sigmoidectomy with excision of the fistula with improvement in his symptoms (Figure, Table). Discussion: A diverticulum is a sac-like protrusion of the colonic wall, developing at well-defined points of weakness where the vasa recta penetrate the circular muscle of the colon. Approximately 4% of patients with diverticulosis develop acute diverticulitis and very few of them develop complications. Fistula formation is more common in men, as the uterus and the broad ligaments are thought to protect the bladder from the inflamed sigmoid colon. Colovesical fistulas should be suspected in any patient who presents with pneumaturia or fecaluria or a male with UTI symptoms and a history of diverticulosis. Diverticular fistulas do not close spontaneously and require surgical management that involves identification and division of the fistula, resection of the involved portion of the colon, and bladder repair if necessary.Figure 1.: Sigmoid Diverticulitis with Colovesical Fistula. Table 1. - Significant Lab Values Temperature on presentation 102.6 WBC count 7500 Hemoglobin 14.9 Blood Urea Nitrogen 19 Creatinine 0.98 Urine Appearance Cloudy Urine Analysis Large Leukocyte Esterase positive Urine Microscopy WBC clumps and Large Blood Lactic Acid trend 2.2 > 0.9 Blood Cultures No growth

Defining diverticular fistula through inpatient admissions: a population study.

Diverticular fistula, a pathologic connection from the colon to the skin or another organ, is an uncommon sequela of diverticular disease. It is generally considered an indication for surgery. The current literature is limited in terms of defining the epidemiology of this disease process. This analysis defines the demographics of fistulous diverticular disease on a national level. A retrospective review of the 2018 National Inpatient Sample (NIS) was conducted, using ICD-10 codes for diverticular disease, diverticular-associated fistulas, and associated surgeries. Demographic factors were compared between groups, and several sub-group analyses were performed. A total of 7,105,498 discharges were recorded: 119,115 (1.68%) with non-fistulizing diverticular disease and 3,843 (0.05%) with diverticular fistula. Patients with diverticular fistula were more likely to be younger (64.7 v 68.2years, p < .0001) and female (57.3% v 55.4%, p = 0.028) than patients with non-fistulizing disease. They were also more likely to undergo surgery (64.9% v 25.7%, p < .0001), to be admitted electively (44.7% v 12.0%, p < .0001), and to have a longer length of stay (LOS) (mean 8.07 v 5.20days, p < .0001). Diverticular fistula patients that underwent surgery were more likely to be male (44.8% v 39.0%, p = 0.003), to be admitted electively (65.3% v 6.7%, p < .0001), and to have longer LOS (mean 8.74 v 6.81days, p < .0001) than those who received medical treatment alone. Diverticular fistula is a rare diagnosis, accounting for 0.05% of total admissions and 3.12% of admissions for diverticular disease. However, this is more common than the previously reported rate of < 0.1% of diverticular disease admissions. While surgery is generally indicated for diverticular fistula, only 64.9% of patients underwent surgical treatment. Although this study is limited by its retrospective nature and use of administrative data, our findings elucidate the prevalence and patterns of inpatient admissions for diverticular fistula in the United States.

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Diverticular Fistula of the Female Urethra on Lithiasis at the District Health Center (CSREF) in Communeii, Bamako, Mali

The diverticulum of the female urethra or sub-urethral pouch is in the form of a cul-de-sac lined with mucous membrane through the muscular layer of the urethra. Thus, it is a site of stasis, urinary infection, formation of calculus or even malignant tumor. The diverticula of the urethra or sub-urethral pouches in women have a prevalence of 0.5% to 6% depending on the series. We report the case of a 61-year-old patient operated for a diverticulum on fistulized urethra complicated lithiasis. Our patient had five pregnancies and five births when she consulted for dysuria, urinary burns evolving since a year. The urogenital examination revealed a partially stenotic urethral meatus and a 3-cm large fistulized intravaginal peri-urethral mass allowing urine leak. The mass was painful and hard at palpation. We performed transvaginal diverticulectomy. The follow-up was simple and the probe was removed two weeks after the surgery. An atomo-pathological examination of the resected diverticulum concluded an aspect compatible with lithiasis urethritis.

Perforation of Meckel’s diverticulum by foreign body. Case study

Meckel’s diverticulum is a congenital anomaly of the gastrointestinal tract, which occurs in 2 to 4 % of the individuals in the general population. There is no gender difference in the frequency of detection, although the incidence of complications among males is 3 to 4 times higher. Of the complications, the most common are bleeding, invagination, intestinal obstruction, perforation, very rarely — bladder — diverticular fistulas and tumors. The clinical case of Meckel’s diverticulum perforation by a wooden chip imitating the acute appendicitis clinic is presented.

Laparoscopic Surgery for Diverticular Fistulas: Outcomes of 111 Consecutive Cases at a Single Institution

BackgroundThe purpose of this study was to review our experience with laparoscopic colectomy and fistula resection, evaluate the frequency of conversion to open, and to compare the perioperative courses of the complete laparoscopic and conversion groups. MethodsThis study is a retrospective analysis of 111 consecutive adult patients with diverticular fistulae diagnosed clinically or radiographically over 11 years at a single institution. Five patients were excluded for preoperative comorbidities. The remaining 106 consecutive patients underwent minimally invasive sigmoid colectomy with primary anastomosis. Preoperative, intraoperative, and postoperative variables were collected from the colorectal surgery service database. A retrospective cohort analysis was performed between laparoscopic and converted groups. ResultsWithin the group, 47% had colovesical fistulas, followed by colovaginal, coloenteric, colocutaneous, and colocolonic fistulas. The overall conversion rate to laparotomy was 34.7% (n = 37). The most common reason for conversion was dense fibrosis. Mean operative time was similar between groups. Combined postoperative complications occurred in 26.4% of patients (21.4% laparoscopic and 37.8% converted, p = 0.075). Length of stay was significantly shorter in the laparoscopic group (5.8 vs 8.1 days, p = 0.014). There were two anastomotic leaks, both in the open group. There were no 30-day mortalities. ConclusionsLaparoscopic sigmoid colectomy for diverticular fistula is safe, with complication rates comparable to open sigmoid resection. We identify a conversion rate which allows the majority of patients to benefit from minimally invasive procedures.

Spontaneous colocutaneous diverticular fistula presenting as perianal abscess

Spontaneous colocutaneous diverticular fistula presenting as perianal abscess

Tu2021 - Early Foley Catheter Removal after Sigmoid Colectomy for Diverticular Colovesical Fistula

Tu2021 - Early Foley Catheter Removal after Sigmoid Colectomy for Diverticular Colovesical Fistula

Evolution of Technique in Performance of Minimally Invasive Colectomies

Hand-assisted laparoscopic surgery is commonly used in colorectal surgery and provides benefit in complex cases. This study examined the minimally invasive surgical trends, patient characteristics, and operative variables unique to patients undergoing hand-assisted laparoscopic surgery. This was a retrospective medical chart review. The study was conducted in a tertiary care medical center. Patients included in the study were those who underwent pure laparoscopic colectomies, hand-assisted laparoscopic colectomies, and traditional open surgery for elective treatment of diverticular disease, colorectal cancer, IBD, and benign polyp disease. Primary outcomes included patient characteristics and operative variables unique to patients undergoing hand-assisted laparoscopic surgery and documentation of operative technique trends within an experienced colorectal group. Diverticular disease characteristics specific to hand-assisted laparoscopic surgery included the presence of dense inflammatory adhesions (p < 0.0001), diverticular fistulas (p < 0.0001), and unresolved phlegmon (p = 0.0003). Characteristics specific for colorectal cancer included intraoperative tumor bulk (p < 0.0001) and the inability to achieve appropriate surgical resection margins (p < 0.001). Similarly, variables identified for benign polyp disease included adhesions (p < 0.0001) and the ability to gain adequate exposure (p < 0.0001). Limited use of hand-assisted laparoscopic surgery was observed in patients with IBD. This was a retrospective, observational study from a single center. Conversion to hand-assisted laparoscopic surgery provides benefit in surgical scenarios where dense inflammatory adhesions, diverticular fistulas, and intra-abdominal postdiverticulitis phlegmon are present. In addition, benefit is observed in patients with colorectal cancer where laparoscopic dissection of bulky tumor proves to be difficult and where the technical ability to obtain margins using pure laparoscopy is compromised. Although our practice has changed to favor pure laparoscopy, hand-assisted laparoscopic surgery continues to play an important role in complex colorectal cases that otherwise would require open surgery (see video, Supplemental Digital Content 1, http://links.lww.com/DCR/A146).

Hand-assisted Laparoscopic Colectomy for Colovesical Fistula Associated With Diverticular Disease

To evaluate the feasibility and short-term outcome of hand-assisted laparoscopic colectomy (HALC) for the treatment of colovesical fistula complicating diverticulitis, we reviewed the files of all 34 patients who underwent surgery for diverticular colovesical fistula in 1999 to 2010 at a major tertiary medical center. Twenty-one were treated with HALC and 13 with open colectomy. There were no differences in demographic parameters among the groups. HALC and open colectomy had similar operating time. HALC was associated with a significantly shorter hospital stay compared with open colectomy (5 vs. 8 d, P=0.001). HALC proved to be technically feasible and safe in this setting. It provided benefits of tactile feedback and manual manipulation as in open colectomy while maintaining the advantages of a minimal invasive approach.

Colovesical Fistula with Multifactorial Etiology Presenting as Recurrent UTI

Purpose: Colovesical fistula is an abnormal communication that occurs between the epithelium-lined lumen of the colon and of the bladder, either directly or via an abscess cavity “the foyer intermediaire of Chavannaz.” An 88-year-old Hispanic woman presented with a2-day history of chills, pneumaturia, fecaluria, dysuria and generalized body pains. Review of systems was unremarkable. The patient was treated for UTI with E. coli two months prior presentation, with nitrofurantoin. Past history includes diverticulosis, HTN, CAD, osteoarthritis, DM, diastolic heart failure, dyslipidemia, and total abdominal hysterectomy 14 years ago. On admission, the patient was febrile; BP of 75/32 mmHg, tachycardic, abdomen soft and non-tender, normal bowel sounds, no organomegaly or flank tenderness. The rest of the systemic exam was normal. Laboratories: Leukocytosis 12.2 with normal distribution and acute kidney injury with Cr of 1.5 mg/dl. A urine analysis revealed turbid urine with large leukocyte rsterase, 50-100 wbc/hpf, and was loaded with bacteria. The urine culture grew E. coli (MDRO) and Enterococcus species sensitive to vancomycin. Daptomycin and vancomycin started with marked clinical improvement on the second day of admission. A computed tomography scan of the abdomen and pelvis revealed colovesical fistula and diverticulosis of sigmoid colon. Urology service was consulted, and the patient was offered surgical management, but opted for medical management. The patient's UTI clinically improved with antibiotics, and renal function returned to normal. Colovesical fistulous tract occurs secondary to inflammatory, infectious, neoplastic, Iatrogenic or traumatic causes. Diverticular disease is the most common cause and up to 65% of diverticular fistulae are colovesical, with the most common segment being the sigmoid, as observed in our patient. Predisposing factors in our patient include hysterectomy, multiple colonoscopies in the past and advanced age. Establishing the diagnosis depends on presentation. CT scan of the abdomen and pelvis is about 90% sensitive. Surgical management is the treatment of choice, and in high-risk patients or those who do not want surgery, conservative treatment with intermittent antibiotic administration may prevent sepsis and renal failure.Figure

Laparoscopic Management of Diverticular Colovesical Fistula: Experience in 15 Cases and Review of the Literature

Colovesical fistulas secondary to diverticular disease may be considered a contraindication to the laparoscopic approach. The feasibility of laparoscopic management of complicated diverticulitis and mixed diverticular fistulas has been demonstrated. However, few studies on the laparoscopic management of diverticular colovesical fistulas exist. A retrospective analysis was performed of 15 patients with diverticular colovesical fistula, who underwent laparoscopic-assisted anterior resection and bladder repair. Median operating time was 135 minutes and median blood loss, 75 mL. Five patients were converted to an open procedure (33.3%) with an associated increase in hospital stay (P = 0.035). Median time to return of bowel function was 2 days and median length of stay, 6 days. Overall morbidity was 20% with no major complications. There was no mortality. There was no recurrence during median follow-up of 12.4 months. These results suggest that laparoscopic management of diverticular colovesical fistulas is both feasible and safe in the setting of appropriate surgical expertise.

Laparoscopic Resection of Chronic Sigmoid Diverticulitis with Fistula

A growing number of operations for sigmoid diverticulitis are being done laparoscopically. There is a paucity of data on the outcome of laparoscopy for sigmoid diverticulitis complicated by colonic fistula. The aim of this study was to compare the results of laparoscopic resection of sigmoid diverticulitis with and without colonic fistula. A retrospective review was conducted of all patients who underwent laparoscopic resection of sigmoid diverticulitis complicated by fistula at a single tertiary care institution over a 7-year period. Comparison was made with a group of patients who underwent resection for diverticulitis without fistula during the same study period. Forty-two patients were analyzed (group 1: diverticular fistula, group 2: no fistula). The median age was similar (49 vs. 50 years, P = .68). A chronic abscess was present in 24% of patients in group 1 and 10% in group 2 (P = .40). Fistula types were colovesical (71%), colovaginal (19%), and colocutaneous (10%). Operation types were sigmoidectomy (57% vs. 81%) and anterior resection (43% vs. 19%) in groups 1 and 2, respectively (P = .18). Ureteral catheters were used more frequently in group 1 (67% vs. 33% [P = .06]). No difference was noted in operative time, blood loss, conversion rate, length of stay, overall complications, wound infection rate, readmission rate, reoperation rate, and mortality. All patients healed without fistula recurrence. Patients with sigmoid diverticulitis with fistula can be successfully treated with laparoscopic excision, with similar outcomes for patients without fistula.

Outcome of Surgery for Colovesical and Colovaginal Fistulas of Diverticular Origin in 40 Patients

IntroductionAccording to literature, colonic resection with a primary anastomosis and no defunctioning ileostomy is a safe treatment for colovesical or colovaginal fistula of diverticular origin. This study investigates the outcome of surgery for this patient group in a regional hospital. MethodsPatients were obtained from a prospective database in the period 2004–2011. Several variables were investigated for their relation with surgical outcome. ResultsA colovesical (n = 35) or colovaginal (n = 5) fistula was diagnosed in 18 men and 22 women. The mean age was 69 years (range, 45–90). A rectosigmoid resection with primary anastomosis was performed in 32 patients. Fourteen patients received a defunctioning ileostomy. Eight patients were treated with a Hartmann procedure. Overall 30-day treatment-related morbidity and mortality was 48 and 8 %, respectively. Major morbidity, because of anastomotic leakage, was mainly observed in the primary anastomosis group without a defunctioning ileostomy. Morbidity and mortality were associated with high body mass index, diabetes, use of corticosteroids, and American Society of Anesthesiologists classification, though not significantly. ConclusionsOne should be liberal in the use of a defunctioning ileostomy in case of a primary anastomosis after colonic resection for a diverticular fistula, in order to prevent high morbidity rates due to anastomotic leakage.

Diverticular fistulation is associated with nicorandil usage.

We observed that a number of patients presenting to our clinic with diverticular fistulation were taking nicorandil for angina. Recognised side effects of nicorandil include gastrointestinal and genital ulceration. The aim of our study was to determine whether nicorandil is an aetiological agent in diverticular fistulation. We conducted a case-control study of patients with diverticular disease related enteric fistulae. Two patient groups were identified: a study group of patients with diverticular fistulae, and a control group with uncomplicated diverticular disease. The proportion of patients who had ever used nicorandil was compared between the two groups. A total of 153 case notes were analysed, 69 patients with fistulae and 84 control patients with uncomplicated diverticular disease. Female to male ratio in both groups was 2:1. The mean age was 71 years in the fistula group and 69 years in the control diverticular disease group (P = ns). Of those with colonic fistulae, 16% were taking nicorandil compared with 2% of the control group (odds ratio 7.8; 95% confidence interval 1.5-39.1; P = 0.008). There was no significant difference in rates of ischaemic heart disease between fistula and control groups. Nicorandil is associated with fistula formation in diverticular disease.

Diverticular fistulation is associated with nicorandil usage

We observed that a number of patients presenting to our clinic with diverticular fistulation were taking nicorandil for angina. Recognised side effects of nicorandil include gastrointestinal and genital ulceration. The aim of our study was to determine whether nicorandil is an aetiological agent in diverticular fistulation. We conducted a case-control study of patients with diverticular disease related enteric fistulae. Two patient groups were identified: a study group of patients with diverticular fistulae, and a control group with uncomplicated diverticular disease. The proportion of patients who had ever used nicorandil was compared between the two groups. A total of 153 case notes were analysed, 69 patients with fistulae and 84 control patients with uncomplicated diverticular disease. Female to male ratio in both groups was 2:1. The mean age was 71 years in the fistula group and 69 years in the control diverticular disease group (P = ns). Of those with colonic fistulae, 16% were taking nicorandil compared with 2% of the control group (odds ratio 7.8; 95% confidence interval 1.5-39.1; P = 0.008). There was no significant difference in rates of ischaemic heart disease between fistula and control groups. Nicorandil is associated with fistula formation in diverticular disease.

Diverticular fistulation is associated with nicorandil usage

We observed that a number of patients presenting to our clinic with diverticular fistulation were taking nicorandil for angina. Recognised side effects of nicorandil include gastrointestinal and genital ulceration. The aim of our study was to determine whether nicorandil is an aetiological agent in diverticular fistulation.We conducted a case-control study of patients with diverticular disease related enteric fistulae. Two patient groups were identified: a study group of patients with diverticular fistulae, and a control group with uncomplicated diverticular disease. The proportion of patients who had ever used nicorandil was compared between the two groups.A total of 153 case notes were analysed, 69 patients with fistulae and 84 control patients with uncomplicated diverticular disease. Female to male ratio in both groups was 2:1. The mean age was 71 years in the fistula group and 69 years in the control diverticular disease group (P = ns). Of those with colonic fistulae, 16% were taking nicorandil compared with 2% of the control group (odds ratio 7.8; 95% confidence interval 1.5-39.1; P = 0.008). There was no significant difference in rates of ischaemic heart disease between fistula and control groups.Nicorandil is associated with fistula formation in diverticular disease.