Enterocolic Fistula Research Articles

S3444 Not All That Fistulizes Is Crohn’s Disease – Ischemic Jejunocolic Fistula

Introduction: Enterocolic fistulae lead to abnormal diversion of gastrointestinal contents from the small intestine to the colon, causing diarrhea and protein energy malnutrition. We describe a rare case of a jejunocolic fistula due to chronic mesenteric ischemia leading to severe chronic diarrhea. Case Description/Methods: A 40-year-old female with morbid obesity, nicotine dependence, type 2 diabetes mellitus was evaluated for epigastric pain and chronic diarrhea. She also had sitophobia and post-prandial urgency, with weight loss of 70 pounds over the last 6 months. She had been diagnosed with extensive thrombosis involving the abdominal aorta with extensions into the celiac artery, common hepatic artery, and left gastric artery, with evaluation revealing a JAK2 V617F mutant disorder. She was diagnosed with chronic mesenteric ischemia. For the evaluation of her diarrhea, she underwent an EGD with gastric and small bowel biopsies that was normal. CT enterography demonstrated an entero-colic fistula (jejunum to cecum). She underwent a colonoscopy which confirmed a 4 mm fistula in the cecum. Random colonic biopsies were normal, and biopsies from the fistula showed active chronic inflammation. Patient also has elevated calprotectin to 2600. Overall evaluation favored this isolated fistula in the setting of complex atherothrombotic disease to be from an ischemic origin rather than related to Crohn’s disease. The patient is currently being nutritionally optimized with plans for a surgical fistula takedown in the future. (Figure) Discussion: Enterocolic fistulae are complex conditions associated with high morbidity and mortality rates. Most fistulae occur following abdominal surgery, in the setting of infection or breakdown of an intestinal anastomosis due to ischemia, tension, or distal obstruction. Spontaneous fistula formation is uncommon (15-20% of cases), and causes include inflammatory bowel disease (specifically Crohn’s disease), diverticular disease, cancer, radiation enteritis and pancreatitis. Chronic ischemia is a very rare cause of spontaneous intestinal fistulization, with scant case reports described in literature. Enterocolic fistula can present with pain, diarrhea, and weight loss, and can be complicated by protein-energy malnutrition, abscesses, and sepsis. Management of the fistula depends on the underlying etiology, with importance given to nutritional optimization. Surgical takedown or endoscopic closure of fistulae remain a viable option in patients with localized disease.Figure 1.: CT enterography demonstrating a jejunocolic fistula (yellow arrow).

Congenital enterocolic fistula discovered by jejunoscopy

Congenital enterocolic fistula discovered by jejunoscopy

Congenital Tubular Duplication of Colon in an Adult Presented by Abdominal Pain and Constipation: A Case Report and Review of the Literature

Introduction: Congenital duplications of the intestinal tract are rare diseases, observed mainly in ileum and stomach, while less than 7% of cases occur in the colon. They are mainly diagnosed during early childhood, while few cases may remain asymptomatic until adulthood. Case Report: We present a 31-year-old female with chronic abdominal pain without significant past medical history. Pre-operative diagnosis was an enterocolic fistula, which was considered after colonoscopy. Abdominal surgery with midline incision was performed for the patient with suspicion of congenital colon anomaly. During the surgery, the surgeon found an additional colon closed loop that originated from the posterior aspect of the transverse colon and was attached posteriorly to the sigmoid colon. Microscopic examination revealed tubular duplication of the colon with marked dilatation, focal mucosal ulceration, granulation tissue, and mild chronic nonspecific inflammation. Discussion: As congenital duplication of colon is a rare condition with non-specific clinical symptoms, high suspicion of the physician and thorough examination can help the diagnosis and surgical treatment as soon as possible to stop patients’ pain and associated problems.

Duodeno-Colonic Fistula Associated With an Intestinal Large B-Cell Lymphoma

Enterocolic fistulae are usually caused by conditions such as Crohn's disease and diverticulitis. Less commonly, it can also be seen in the setting of prior surgeries, foreign bodies, pancreatitis, or malignancy. Here we reported a rare case of a spontaneous duodeno-colonic fistula caused by intestinal large B-cell lymphoma. This is a 69 year old male with a history of diabetes mellitus who presented with diarrhea and weight loss of 20 pounds for 5 weeks. He described rapid onset of 5 to 6 daily episodes of non-bloody watery stools associated with nausea, but no vomiting, abdominal pain or fever. There was no recent use of antibiotics, no recent travel or sick contacts. He has no history of Crohn's disease or diverticulitis. He was afebrile and physical exam is unremarkable. Laboratory testing revealed normal complete blood count, electrolytes, serum calcium, thyroid-stimulating hormone, and hepatic panel. A computed tomographic (CT) scan of the abdomen showed mild wall thickening and stranding surrounding the proximal duodenum and the splenic flexure of colon that was measuring up to 15 mm in diameter and multiple enlarged lymph nodes within the mesentery. Additionally, there was suggestion of a duodeno-colonic fistula. An upper endoscopy and colonoscopy were performed. Upper endoscopy revealed a fistulous tract in the transverse duodenum with refluxing of stool, however no duodenal mucosal mass seen. On colonoscopy, a large infiltrative mass with fistula near the splenic flexure was identified, but the mass was not transferable to the proximal colon. Histology was consistent with diffuse large B-cell lymphoma which stained negative for CD3 strongly positive for CD20. The patient was taken to the operating room with colorectal and hepatobiliary surgery with plans for an en bloc left colectomy, partial gastrectomy and small bowel resection and partial pancreatectomy. His post-operative course was complicated by a pancreatic duct leak which is well managed with a percutaneous drain and he will soon be initiated chemotherapy. For sudden onset of diarrhea with associated systemic symptoms suspicious for an underlying organic cause, imaging and endoscopic evaluation should be considered. The initial treatment of enterocolic fistulae is to correct fluid and electrolyte abnormalities, but in our case, oncologic treatment of B cell lymphoma could not be initiated until after surgical resolution of nutrient wasting diarrhea.1610_A Figure 1. CT showed colonic wall thickening with possible duodeno-colonic fistula1610_B Figure 2. Colonoscopy showed a large infiltrative mass with fistula near the splenic flexure.1610_C Figure 3. Pathology showed colonic mass with fistula is identified extending from the colonic mucosa to the duodenal mucosa.

WITHDRAWN: A late diagnosis of a complicated Meckel’s diverticulum - The first case of an enterocolic fistula secondary to a Meckel’s diverticulum in a paediatric patient and review of the literature

WITHDRAWN: A late diagnosis of a complicated Meckel’s diverticulum - The first case of an enterocolic fistula secondary to a Meckel’s diverticulum in a paediatric patient and review of the literature

小腸と瘻孔を形成した結腸癌の2例

大腸癌が消化管に内瘻を形成するのはまれである．今回，空腸結腸瘻と回腸結腸瘻を形成した大腸癌の2例を経験したので報告する．症例1:52歳，女性．腹痛とイレウス症状で受診．腫瘍マーカーは異常高値を示し，CTでS状結腸腫瘍と肝転移と診断した．S状結腸切除術および空腸合併切除術を施行した．腫瘍は中分化腺癌で空腸と瘻孔を形成していた．術後6カ月で原病死した．症例2:82歳，女性．腹膜炎症状で受診．CTで回盲部腫瘍を認めた．穿孔性虫垂炎による腹膜炎と診断したが，回盲部腫瘍と回腸・横行結腸浸潤のため拡大結腸右半切除術を施行した．盲腸腫瘍は低分化腺癌で回腸に瘻孔を形成し，さらに横行結腸の漿膜下層にまで浸潤していた．術後2年無再発生存中である．結腸癌による小腸結腸瘻はまれで本邦では自験例を含め35例であった．本疾患は他臓器浸潤例ではあるが，遠隔転移がないときは積極的な合併切除で予後は期待できるものと思われた．

Comparing over-the-scope clip versus endoloop and clips (KING closure) for access site closure: a randomized experimental study

A safe technique is essential for successful access site closure in Natural Orifice Translumenal Endoscopic Surgery (NOTES) and for closures of iatrogenic perforations. To compare an over-the-scope clip (OTSC) versus an endoloop + endoclips closure technique (KING closure). 40 minipigs underwent NOTES peritoneoscopy with liver biopsy. Gastrotomies and rectotomies were closed with OTSC (n = 20; 10× stomach, 10× rectum) or KING closure (n = 20; 10× stomach, 10× rectum). The animals were euthanized 28 days after the procedure. The main outcome variables were technical feasibility, effectiveness, and healing. Stomach: All but one closure (KING) was successfully completed. The times of closure were similar between the techniques. At necropsy, all access sites were healed. In two animals (1× KING, 1× OTSC), an abscess, probably related to the closure technique, was found. Histologically, transmural healing with muscular bridging was observable in nine pigs for KING versus two pigs for OTSC closure (p = 0.003). Inflammation was present in three pigs for KING versus seven pigs for OTSC closure (p = 0.08). Rectum: All closures were successfully completed. The times of closure were similar between the techniques. At necropsy, all closure sites had healed. Transmural healing with muscular bridging was present in nine pigs for KING versus two pigs for OTSC closure (p = 0.003). Inflammation was present in two pigs for KING versus seven pigs for OTSC closure (p = 0.03). In one animal (OTSC), an enterocolic fistula developed in the proximity of the closure site. OTSC and KING closure are comparable closure techniques in terms of technical feasibility and effectiveness. KING closure provides a superior histological outcome compared with OTSC closure.

Enterocolic Fistula: A Rare Presentation of Cytomegalovirus Infection

In the present report, the first reported case of cytomegalovirus (CMV)-associated enterocolic fistula in an HIV/AIDS patient is described. CMV colitis is the second most common presentation of CMV infection in immunocompromised patients. CMV-associated enteric fistulae are an exceedingly rare complication, with only four previous cases described: a gastrocolic, an enterocutaneous, a rectovaginal and a colocutaneous fistula. Management of these patient demonstrates the importance of treating the precipitating viral infection before considering surgical intervention of the enterocolic fistula.

Ingestión accidental de prótesis dental fija (cantilever) en paciente con historia de carcinoma de colon

This clinical report describes a case of accidental swallowing of three units cantilever porcelain fused metal bridge in a 51-years-old male with history of colon cancer and reversible colostomy four years ago. While the kind of the ingested foreign body and the prior gastrointestinal conditions recommend a surgical management decision to avoid the risks for perforation or obstruction, in our case the management decision was the conservative approach because of the asymptomatic condition and the radiographic observation of the normal pass the alimentary tract without complications. The fixed dentures should be secure and stable but an incorrect design of the bridge (wrong indication of cantilever; short post systems) are at increased risk of important potential harms (inhalation, oesophageal perforation, enterocolic fistula, intestinal obstruction), invasive intervention or even death, all with medicolegal consequences.

Enterolith with enterocolic fistula: The diagnostic approach

An enterolith is a mixed concretion formed in GIT, usually rare in humans. Primary enteroliths are formed in small bowel, typically within a diverticulum and secondary enteroliths in gallbladder. This case report highlights the presence of an enterocolic fistula; probably a postradiotherapy complication; and an enterolith without associated small bowel or colonic diverticuli. We have discussed the various diagnostic modalities used to reach a preoperative diagnosis of this rare condition. Imaging plays an important role in the detection and management of acquired gastrointestinal fistulas. The more routine use of cross-sectional imaging (especially computed tomography and magnetic resonance imaging) has altered the standard sequence of radiologic evaluation for possible fistulas, but fluoroscopic studies remain a valuable complement, especially for confirming and defining the anomalous communications.

An Abscess in Crohnʼs Disease Identified by MR Enterography that Could Not be Diagnosed by CT Scan

Purpose: Crohn's disease can lead to penetrating complications in the gastrointestinal tract and result in abscess formation. Accurate identification of complications is important when selecting appropriate therapies. Methods: We report a patient with Crohn's disease with an abdominal abscess that was correctly identified with Magntetic Resonance Enterography (MRE), but not confirmed by CT scan. Results: A 27 year old man with known Crohn's disease was admitted to the hospital with abdominal pain, vomiting, and a fever. He was diagnosed with Crohn's ileitis one year prior to admission. At that time he reported abdominal pain and diarrhea and a CT scan revealed a markedly thickened, inflamed ileum with several enteroenteric and enterocolic fistulae and right hydronephrosis. A colonoscopy confirmed the diagnosis of Crohn's disease. His ureter was stented and he was treated with antibiotics and initiated on certolizumab. His symptoms resolved and he remained in remission for several months on certolizumab. He later developed recurrent abdominal pain with vomiting and a fever. He was admitted to the hospital and an MRE revealed dilated small bowel with a thickened, inflamed ileum and several fistulae. On initial review of the standard T2-weighted and enhanced fat-suppressed Tlweighted images, multiple fluid filled loops of small bowel were present in the right lower quadrant, and the confident distinction between intraenteric and extraenteric fluid was considered difficult by a MR trained radiologist with experience in MR enterography. However, diffusion-weighted images obtained as part of the MR enterography protocol clearly defined an extraluminal fluid collection with restricted diffusion, interpreted as abscess. Percutaneous drainage was attempted using CT-guidance to allow for an elective surgery at a later date. However, CT was unable to confidently delineate between the abscess and adjacent bowel loops, and the drainage procedure was aborted. The patient was taken for urgent surgery where the findings of the MRE were confirmed including a thickened, inflamed ileum with fistulae and a large abscess. The abscess was drained, the ileum was resected, and a temporary ileostomy was created. Conclusion: While traditional imaging with CT is often used to evaluate for complications of Crohn's disease, confident distinction between abscess and adjacent bowel loops can be difficult in the absence of excellent opacification of the bowel with enteric contrast material. Most CT enterography protocols utilize negative enteric contrast material to allow for better depiction of bowel wall enhancment. MRE with diffusion-weighted imaging provides an alternate imaging technique, without radiation, that may provide more accurate information in select cases. Disclosure: Dr Leyendecker: Speaker, Bracco Diagnostics; Speaker, Bayer Healthcare; Research grant, Bracco Diagnostics.

Enterocolic fistula associated with a gastrointestinal stromal tumor

Enterocolic fistula associated with a gastrointestinal stromal tumor

A case of entero-colic fistula formation resulting from stent migration inserted for obstructing left colonic tumour

Dear Editor: Management of malignant obstruction of large bowel is associated with a number of challenges. Favourable outcomes have been reported with the use of SEMS both for cancer palliation and treatment of acute obstruction as a “bridge to surgery”. Colonic stent migration can occur in 3– 22% of cases. Stenosis from extrinsic compression and laser pre-treatment or chemotherapy may be factors precipitating stent migration. We experienced one case, however, of a patient in whom a SEMS implanted for obstructing distal descending colon tumour resulted in an entero-colic fistula formation due migration. We describe this complication and discuss the possible causes of fistula formation. An 85-year-old man was admitted with a closed loop large bowel obstruction. A CT scan confirmed an obstructing stricture in the distal descending colon. His past medical history included MI and CABG in 2000, a right hemicolectomy for Dukes B adenocarcinoma in 2001. Laparotomy for a defunctioning procedure was planned but just prior to that he suffered a non-ST elevating myocardial infarction. Therefore, a self-expanding metallic stent was placed successfully in the descending colon stricture. A week later, he represented with acute large bowel obstruction due to blocked stent. Laparotomy revealed an obstructing tumour. A Hartmann’s procedure was performed with removal of left colon and with an assumption that the stent would be in the resected specimen, as palpation of the remaining colon did not identify the stent. Histology confirmed Dukes B adenocarcinoma. He was readmitted 2 weeks later with bleeding from the stoma but settled quickly and was sent home once again. Six weeks after the Hartmann’s procedure, he was admitted with vomiting, lower abdominal pain and loose stools for 2 weeks. A plain abdominal radiograph revealed the stent present in the colon. At laparotomy, the stent had eroded through the colonic wall 20 cm proximal to the stoma and fistulated into two loops of jejunum approximately 30 cm from the duodeno-jejunal flexure. The fistula was taken down, small bowel and colon were repaired primarily and a reversal of Hartmann’s was performed with a covering defunctioning loop ileostomy. Post-operatively, the patient suffered from pneumonia and with gradual deterioration, died with respiratory failure. Acute colorectal obstruction is traditionally approached with segmental colectomy and diverting colostomy. However, up to 25–40% of patients never undergo colostomy closure, and colostomy closure itself carries a 7% mortality rate. Tumour ingrowth and overgrowth resulting in the recurrence of obstructive symptoms is the main long-term complication of SEMS placement. The use of covered stents is believed to reduce tumour ingrowth; however, it may lead to an increased stent migration rate. Wada et al. reported a case of stent perforation and ileosigmoid fistula formation in a patient with Crohn’s disease. Suzuki et al. showed seven of 36 patients suffered from stent migration with one of 36 resulting in fistula formation. Sofiya et al., in her 5-year literature review, showed no fistula formation and only 3% stent migration. Migration and fistula formation is a rare but recognised complication of colonic stent placement for obstructed colon. Int J Colorectal Dis (2009) 24:353 DOI 10.1007/s00384-008-0627-5

Disappointing outcome of autologous stem cell transplantation for enteropathy-associated T-cell lymphoma

Background Despite treatment, enteropathy-associated T-cell lymphoma has a very poor outcome. Chemotherapy can be complicated by small bowel perforation, gastrointestinal bleeding and development of enterocolic fistulae. Here we report on the feasibility, safety and efficacy of high-dose chemotherapy followed by autologous stem cell transplantation in patients with enteropathy-associated T-cell lymphoma (three upfront and one at relapse), with or without prior partial small bowel resection. Methods Four patients [two males, two females, mean age 65 years (range 60–69 years)] received high-dose chemotherapy followed by autologous stem cell transplantation. Partial small bowel resection has been performed in three patients. Results All four patients completed the mobilization and leucopheresis procedures successfully and subsequently received conditioning chemotherapy and transplantation. Engraftment occurred in all patients. No major non-haematological toxicity or transplantation-related mortality was observed. One patient has ongoing complete remission 32 months after transplantation. Three patients died from relapse within few months after autologous stem cell transplantation. Conclusions Autologous stem cell transplantation seems unsatisfactory for patients with enteropathy-associated T-cell lymphoma. More intensive conditioning and aggressive chemotherapy with/or without targeted immunotherapy as well as allogenous stem cell transplantation needs to be explored.

Laparoscopic vs . Hand-Assisted Laparoscopic Sigmoidectomy for Diverticulitis

Sigmoid colectomy for diverticulitis can be technically challenging because of severe inflammation in the left-lower quadrant and pelvis. We hypothesized that hand-assisted laparoscopic technique may facilitate laparoscopic completion of this surgery while retaining the short-term benefits associated with "pure" laparoscopic surgery, in which an incision is made only for extracting the specimen. This study was designed to compare the outcomes of patients who underwent totally laparoscopic or hand-assisted laparoscopic sigmoidectomy for diverticulitis. We reviewed our prospectively collected patient database from July 2001 to June 2004 and compared the intraoperative data and postoperative outcomes of patients who underwent elective laparoscopic or hand-assisted laparoscopic sigmoidectomies for diverticulitis. Complicated patients (with abscess or fistulas) also were separately analyzed. The hand-assisted laparoscopic (mode age, 57 years; 48 percent male) and laparoscopic sigmoidectomy (mode age, 56 years; 90 percent male) groups were similar with regard to age and gender. Overall, patients who underwent laparoscopic (n = 21) vs. hand-assisted laparoscopic (n = 21) sigmoidectomies had a significantly longer operative time (197 +/- 42 vs. 171 +/- 34 minutes, P = 0.04) and shorter incision length (5 +/- 2.1 vs. 9.3 +/- 4.1 cm, P = 0.0001). Patients with complicated diverticulitis (n = 14; abscess, colovesical fistula, enterocolic fistula) who underwent laparoscopic sigmoidectomies (n=4) had a significantly longer operative time compared with hand-assisted laparoscopic sigmoidectomy (n = 10) group (255 +/- 18 vs. 177 +/- 34 minutes, P = 0.001). Conversion rate for the laparoscopic group was significantly higher (3/4 vs. 1/10, P = 0.04, Fisher exact) when complicated diverticulitis was present. There were no differences in postoperative outcomes or incision lengths in the complicated group. Outcomes after hand-assisted laparoscopic sigmoidectomy for diverticulitis are similar to those seen in the pure laparoscopic method, with lower conversion rates and shorter operative times. Hand-assisted laparoscopic sigmoid resection for diverticulitis is an attractive alternative to a "pure" laparoscopic method in complicated cases.

Endoscopic diagnosis of malignant enterocolic fistula caused by ileal lymphoma

Malignant fistula of the GI tract is a rare clinical condition. Although this complication could readily be diagnosed by radiographic imaging, colonoscopy has also been diagnostic. 1 Matsumoto T Iida M Kuwano Y Furuse M Kimura Y Fujishima M Endoscopic demonstration of malignant duodenocolic fistula: two case reports. Endoscopy. 1996; 28: 268 Crossref PubMed Scopus (1) Google Scholar , 2 Roberts PL Coller JA Corriveau S Nielsen-Whitcomb FF Malignant duodenocolic fistula diagnosed by endoscopy. Surg Endosc. 1989; 3: 112-114 Crossref PubMed Scopus (4) Google Scholar , 3 Becheur H Piketty C Bloch F Levoir D Aubertin JM Bouillot JL et al. Endoscopic diagnosis of a duodenocolic fistula due to a non-Hodgkin's lymphoma in a patient with AIDS. Endoscopy. 1996; 28: 528-529 Crossref PubMed Scopus (3) Google Scholar No previous reports have described enteroscopic features of malignant enterocolic fistula. We herein report a rare case of ileal lymphoma with an enterocolic fistula that was confirmed by ileoscopy and colonoscopy.

Enteropathy-type intestinal T-cell lymphoma: clinical features and treatment of 31 patients in a single center.

We report the clinical features and treatment of 31 patients with a diagnosis of enteropathy-type intestinal T-cell lymphoma treated at the Wessex Regional Medical Oncology Unit in Southampton between 1979 and 1996 (23 men, eight women). Patients were identified from our lymphoma database. Details of history, physical examination, staging investigations, treatment, and outcome were taken from patient records. Twelve patients (35%) had a documented clinical history of adult-onset celiac disease, and a further three had histologic features consistent with celiac disease in resected areas of the small bowel not infiltrated with lymphoma. After diagnosis, 24 (77%) of the 31 patients were treated with chemotherapy; the remaining seven had surgical treatment alone. More than half were unable to complete their planned chemotherapy courses, often because of poor nutritional status; 12 patients required enteral or parenteral feeding. A response to initial chemotherapy was observed in 14 patients (complete response, n = 10; partial response, n = 4). Observed complications of treatment were gastrointestinal bleeding, small-bowel perforation, and the development of enterocolic fistulae. Relapses occurred 1 to 60 months from diagnosis in 79% of those who responded to initial therapy. Of the total 31 patients, 26 (84%) have died, all from progressive disease or from complications of the disease and/or its treatment. The actuarial 1- and 5-year survival rates are 38.7% and 19.7%, respectively, with 1- and 5-year failure-free survival rates of 19.4% and 3.2%, respectively. The prognosis for these patients is poor. This, in part, reflects late diagnosis and poor performance status at the time of presentation. The role of salvage treatments and high-dose chemotherapy at relapse is not clear. However, it is encouraging that there are five long-term survivors in our patient population.

Blind loop syndrome. Diagnosis by In-111-labeled leukocyte scintigraphy.

A 50-year-old man had vitamin B12 deficiency. Gastrointestinal radiographs showed a fistula between the small bowel and the transverse colon and a normal terminal ileum. An In-111-labeled leukocyte scan was performed. Further questioning of the patient revealed that a childhood appendectomy had been performed in difficult circumstances and necessitated the formation of an enterocolic fistula. Increased uptake in a blind loop has not been described before and may contribute to increased uptake in some patients with complicated Crohn's disease (i.e., those with fistulae or multiple resections) in whom it could be misinterpreted as active inflammation.

Laparoscopic surgery for lower gastrointestinal fistulas.

Increased experience and improved instrumentation have lead to a reduction in morbidity and a commensurate increase in the spectrum of laparoscopic indications. The purpose of this study was to assess the feasibility of laparoscopic surgery in patients with gastrointestinal fistulas. Between March 1993 and March 1995, patients with gastrointestinal fistulas who were laparoscopically treated were analyzed for age, gender, diagnosis, type of procedure, operative time, conversion rate, length of postoperative hospitalization, time until oral intake and return of bowel function, morbidity, and mortality. Ten patients (five females; five males) with a mean age of 49.7 (range 20-86) years were preoperatively diagnosed as having the following fistulas: colocutaneous fistula due to diverticulitis (one), enterocolic fistula (two)-due to Crohn's ileocolitis (one) and due to diverticulitis (one)-pouchvaginal fistula after restorative proctocolectomy for familial adenomatous polyposis (two), colofallopian fistula due to diverticulitis (one), rectourethral fistula due to Crohn's disease (one), high transsphincteric fistula due to perianal Crohn's disease (one), enteroenteric fistula due to Crohn's disease (one), and colovesical fistula due to diverticulitis (one). Procedures performed consisted of sigmoidectomy with coloproctostomy (four), ileocolic resection (two), small-bowel resection with ileostomy (one), and diverting loop ileostomy (three). A complex jejunal enterotomy was noted in one (10%) patient. The mean operative time was 195 (range 75-360) min and mean postoperative hospital stay was 6.1 (range 3-12) days. Two additional cases were converted to open procedures for extensive disease (one) and adhesions (one). The patients started oral intake after a mean of 2.2 (range 1-5) days and bowel function returned after a mean of 3.4 (range 2-7) days. One patient required laparotomy on postoperative day 7 for a malrotated loop ileostomy. Laparoscopic colorectal surgery is feasible in patients with simple lower gastrointestinal fistulas. The morbidity rate of 10% and length of hospitalization of 6 days are similar to results after laparoscopic procedures for "simpler" colorectal pathology. However, the 30% conversion rate is higher, attesting to the challenging nature of these conditions.

Treatment of diarrhoea due to enterocolic fistula with octreotide in a terminal cancer patient

A patient is described whose output from an enterocutaneous fistula was greatly reduced using octreotide, a somatostatin analogue.