Site Of Fistula Research Articles

It is time to retire Goodsall's Rule: the Midline Rule is a more accurate predictor of the true and natural course of anal fistulas.

On May 6, 1887 at a meeting of the West London Medico-Chirurgical Society, original observations attributed to D. H. Goodsall described an association between the secondary (external) sinus opening and the location of the primary (internal) opening of an anal fistula: posterior external sinuses had a midline origin and anterior external sinuses took a straight path to their internal origin-eponymously known as Goodsall's Rule. However, over the last century, published reports support the midline as the primary (internal) origin of all anal fistulas, thus challenging the predictive accuracy of Goodsall's Rule and prompting this expansive review. A literature search was performed for studies describing the relationship between the secondary (external) opening and the primary (internal) opening of anal fistulas, including recent reports of the positive predictive value (PPV) of Goodsall's Rule. The studies were evaluated to determine the validity of Goodsall's observations. The midline was the dominant, primary (internal) opening site of all anal fistulas with up to 95% accuracy. Goodsall's Rule was inaccurate when applied to anal fistulas with an anterior off-midline external sinus opening which tend to mirror posterior off-midline external sinuses and curve to a midline origin, rather than take a straight course to a primary (internal) opening, as predicted by Goodsall. Use of the Midline Rule had superior predictive accuracy, reflected in an increase in overall PPV of the location of the primary (internal) origin from 49% using Goodsall's Rule to 71% using the Midline Rule (57-62% for men, 31-90% for women). Goodsall's Rule falls short in predicting the natural course of anal fistulas with an anterior off-midline external sinus opening, especially for women. Given the increased risk of fecal incontinence related to surgical intervention for anterior-based anal fistulas, especially in women, dependence on Goodsall's Rule to guide the surgeon may result in "disastrous consequences". The preponderance of evidence over the last century favors the Midline Rule as a more accurate predictor of the true and natural course of anal fistulas, regardless of the location of the external sinus opening.

The early outcome of primary anterior sagittal approach for low anorectal malformations in female patients.

Objective:To document our experience of the primary anterior sagittal anorectoplasty (ASARP) in female patients with lower and wide fistula in term of the early post operative outcome.Methods:A retrospective descriptive study was conducted in one surgical unit of the National Institute of Child Health Karachi, from January 2010 to April 2018. The study included female patients with diagnosis of imperforate anus with wide Vestibular or Perineal fistula with minimal or no straining during defecation and no excoriation of perineum. All patients underwent primaryASARP. Data regarding the age of the patients, site of fistula, the difficulties in dissection, post operative complications, stoma and re-do ASARP needed, were documented. Wound assessment was done during hospital stay, at two weeks and then at three months after surgery. Outcome was documented in terms of complications of surgery and cosmetic appearance of perineum. Data was analyzed on SPSS version 20.Results:A total of 70 patients underwent primary surgery, 48(68.57%) females had perineal fistula while 22(31.42%) had vestibular fistula. Age ranges between three months to 276 months with median of 6±39.73 months. No major injury to the rectal or vaginal wall occurred during surgical procedure. In early post-operative period, 12(17.14%) patients had wound infection with or without various extent of disruption. A total of seven (10.11%) patients underwent stoma formation, six (8.57%) patients because of wound disruption with in a week of primary surgery and in one patient due to severe anal stenosis and retraction of anal segment within three month follow up. Median hospital stay was 5±1.52 days. In 38(54.28%) paients complete wound healing occurred with no per or post operative complications. In 25(35.71%) patients, minor complications were noted and treated accordingly and results were labelled satisfactory with acceptable perineal appearance.Conclusion:The single stage procedure can be a good choice for both vestibular and perineal fisula. In majority of cases wound heals completely with minimal or no scaring and give good cosmetic results.

P188 Coronary fistula

Abstract Background A coronary arterial fistula is a connection between one or more of the coronary arteries and a cardiac chamber or great vessel. Most of these fistulas are congenital in origin and remain asymptomatic until the second or third decade of life. After this period, patients may present with symptoms of easy fatigue, myocardial infarction, atrial arrhythmias or heart failure. Also, coronary steal syndrome could be observed, leading to myocardial ischemia of the cardiac wall which is supplied with blood by the corresponding artery. Case We present a 50-year-old female who was submitted to ED with palpitations. From her medical history, she suffered from arterial hypertension and dyslipidemia. The clinical evaluation revealed a continuous murmur that could be heard mainly at Aortic Valve point. The only abnormal finding from blood exam was troponin: 288 pg/ml. Admission ECG was consistent with supraventricular tachycardia and the patient was treated with intravenous solution of adenosine. Bedside echocardiography revealed an abnormal flow coming out from the aortic root, next to the right coronary casp. Transesophageal echocardiography confirmed the previous findings. The main differential diagnosis includes patent ductus arteriosus, ruptured sinus of Valsalva aneurysm, aortopulmonary window and coronary arterial fistula although other congenital arteriovenous shunts need to be excluded. For further evaluation, the patient underwent cardiac MRI which revealed right atrial enlargement and dilatation of proximal right coronary artery, from which a dilated arterial branch originates and passes between the aortic root and the right atrium. All these could be attributed to the presence of an arterial fistula. Thus, the patient went on to have CT coronary angiography which confirmed the hypothesis. In particular, CT angiography depicted a fistula between the right coronary sinus and the posterior wall of right atrium. Conclusion This case highlights the use of CT coronary as robust tool for investigating the origin, course and drainage site of a coronary arterial fistula. Abstract P188 Figure. FISTULA

Chyluria: An Unending Illness- A Case Report

Chyluria is the passage of milky urine due to a lymphourinary fistula. It is secondary to lymphatic stasis caused by obstruction of the lymphatic flow. It is caused by the parasite Wuchereria bancrofti in more than 95% of cases in tropical countries. Chyluria occurs in 2% of filarial-infested patients. When an abnormal connection between intestinal lacteals and the urinary tract develops, chyluria appears. The diagnostic approach is aimed to define the site of lymphourinary fistula. It is a benign disease that can be controlled by medical treatment and dietary restrictions. A small number of patients require surgical intervention. The 45-year-old thin built woman was suffering from chyluria, flank pain in the abdomen, weakness and loss of weight for the last 10 years. The serum test for circulating adult filarial antigen was positive in moderately high titer. Antifilarial treatment was advised. The symptoms improved for three months and again relapsed.

Pedicled Island Latissimus Dorsi Myocutaneous Flap in Reconstruction of Complex 3D Head & Neck Defects after Tumor Ablation: Refinement of Flap Insetting Techniques in Selected Patients

Introduction: Nowadays free tissue transfer is consideredthe golden slandered in reconstruction of major defects inhead and neck regions. Pedicled flaps, however, still haverole in high risk patients. Pedicled island LD myocutaniousflap can provide a massive amount of tissue that can be utilizedand manipulated to reconstruct complex 3D defects withminimal donor site morbidity. Although has been describedlong time ago, the literature is very deficient regarding methodsand techniques to manipulate the flap during transfer andinsetting to fit complex two or three layered 3D reconstruction.The aim of this study is to describe our techniques in analgorithmic pattern within the context of our case series.Methods: In this retrospective study we present 32 patientsunderwent island LD myocutaneous flap for reconstructionof complex head and neck defects (19 patients underwentpartial or total pharyngeal reconstruction ± neck skin, and 13patients underwent lower face ± mandibular reconstructionwith intra oral extension). Average age was 56 years andselection criteria for this technique includes; depleted neckvessels from previous surgery, frozen neck after pre-operativeradiation together with high risk patients. Technical considerationin flap design and in-setting were reported in detailsaccording to the site of reconstruction.Results: We have a single mortality in post-operativeperiod in a medically morbid patient. No whole flap failurein all patients. 2 patients (6.3%) had partial flap loss. Eightpatients (25%) had other complications like fistula, wounddehiscence and donor site problems. Recurrence happened in3 patients. Over all complication rate is 31%. Donor site andwound related complications were treated conservativelyhowever other complications such as flap vascular insult,partial necrosis and delayed fistulas were treated surgically(9.3%).Conclusion: The island subcutaneous LD myocutaniousflap is a very useful tool in reconstruction of complex 3Dhead and neck defects in selected patients. The rate of complicationsare comparable with free tissue transfer whenappropriate techniques are used.

Perioperative pancreatic enzyme replacement therapy reduces morbidity in patients undergoing pancreatoduodenectomy

Introduction: Exocrine pancreatic insufficiency (EPI) is a common entity in patients scheduled for pancreatoduodenectomy due to obstruction of the pancreatic duct. The treatment for EPI is pancreatic enzyme replacement therapy (PERT) but this is not routinely prescribed in patients undergoing PD. The aim of this study was to examine the effects of perioperative PERT on the incidence of postoperative pancreatic fistula (POPF) and surgical site infections (SSI) in patients undergoing PD. Materials & Methods: Patients undergoing PD during the period January 2014 to December 2017 were maintained database. The electronic medical record was reviewed to determine the presence of symptoms indicative of EPI and the use of PERT during the pre- and post-operative periods. The presence of a dilated pancreatic duct was ascertained through review of pre-operative cross-sectional imaging. Patients were divided into 3 groups: patients who received preoperative PERT continued into the postoperative period (Preop PERT); patients who received only postoperative PERT (Postop PERT); and patients who did not receive PERT (No PERT). A POPF was defined according to the International Study Group of Pancreatic Fistula and classified as biochemical leaks (A) or clinically significant (B or C). SSIs were classified as superficial, deep, and organ-space. The incidence of SSI and POPF were compared between groups. Results: Of 327 patients who underwent a PD, 239 (73%) had evidence of EPI, with a dilated pancreatic duct identified in 203 (62.0%) and symptoms of EPI in 142 (43.4%). The Results are summarized in Table 1. Conclusion: Patients who received preoperative PERT had lower rates of POPF both overall and clinically relevant POPF compared to those receiving postoperative PERT or no PERT. The preop PERT group also experienced less SSIs. Routine preoperative use of PERT should be considered in patients undergoing PD.

Successful use of a novel biological plug in the percutaneous treatment of a refractory gastro-cutaneous fistula following omental patch repair of perforated peptic ulcer

Background: Gastro-cutaneous fistula following re-leak of omental patch repair of perforated peptic ulcer is a very rare but challenging surgical complication. We describe the use of a novel biological plug as a viable repair for gastro-cutaneous fistula that failed medical, endoscopic, and operative management. Additionally, we present a thorough literature review of reported cases of gastro-cutaneous fistulae following omental patching of peptic perforations to further highlight their treatment challenges. Summary: A 69-year-old man underwent repair of a perforated pyloric ulcer with a pedicled omental patch. After one week, patient developed a re-leak from the omental patch, and underwent a second laparotomy with repeat omental patching of the gastric perforation. Ten weeks after the second operation, the patient developed a gastro-cutaneous fistula that failed conservative management with nil per os and enteral nutrition delivered distal to the fistula site; multiple image-guided percutaneous attempts at fistula closure by interventional radiology via fibrin sealant injection and collagen-based vascular closure device; and endoscopic clipping by gastroenterology. Ultimately, this refractory gastro-cutaneous fistula was closed with a novel biological plug (Biodesign® Enterocutaneous Fistula Plug, Cook Biotech). Conclusion: Gastro-cutaneous fistulae following omental patching of perforated peptic ulcer represent a significant complication requiring a multidisciplinary management approach. The Biodesign® Enterocutaneous Fistula Plug offers a promising new tool for the non-operative treatment of refractory gastro-cutaneous fistulae.

Endovascular treatment of hepatic arterioportal fistula complicated with giant portal vein aneurysm via percutaneous transhepatic US guided hepatic artery access: a case report and review of the literature

BackgroundHepatic arterioportal fistulas are rare, abnormal, direct communications between hepatic artery and portal venous system. Treatment options shifted from surgery to endovascular interventions. Catheterization may be challenging. We report a case of a hepatic arterioportal fistula treated successfuly with Amplatzer Vascular Plug II via percutaneous transhepatic hepatic artery access after failed transfemoral approach.Case presentation58 year old woman presented with right heart failure, kidney insufficiency and massive ascites related to portal hypertension caused by hepatic arterioportal fistula. She had a history of previous abdominal surgery. Colour Doppler ultrasound and computed tomography revealed a giant portal vein aneurysm related to large hepatic areterioportal fistula. Endovascular treatment was planned. Catheterization of the hepatic artery could not be realized due to severe tortuosity and angulation of the celiac artery and its branches. Access to the hepatic artery was obtained directly via percutaneous transhepatic route and fistula site was embolized with Amplatzer Vascular Plug II and coils. Immediate thrombosis of the aneurysm sac and draining portal vein was observed. Patients clinical status improved dramatically.ConclusionTranscatheter embolization is the first choice of the treatment of hepatic arterioportal fistulas but the type of the therapy should be tailored to the patient and interventional radiologist should decide the access site depending on his own experience if the routine endovascular access can not be obtained.

2298 Immediate Laparoscopic Nontransvesical Repair with Omental Interposition for Vesicovaginal Fistula Developing after Total Laparoscopic Hysterectomy

Video Objective To investigate the safety and feasibility of laparoscopic management for vesicovaginal fistula developing after TLH. Setting Case study, University hospital in Korea. Interventions A 51-year-old Korean woman underwent of immediate laparoscopic management for vesicovaginal fistula developing after total laparoscopic hysterectomy. A 51-year-old Korean woman was referred to my department for having urinary leakage two weeks before. She underwent total laparoscopic hysterectomy due to heavy vaginal bleeding and leiomyoma four weeks ago. We performed a laparoscopic vesicovaginal fistula repair with omental interposition on November 8th, 2016. We encountered a large adhesion from prior surgery in the pelvic cavity, so performed adhesiolysis using a harmonic sheers. After adhesiolysis, I performed bilateral ureterolysis that continued to the posterior bladder until it reaches the vesicovaginal space, which is then sharply dissected laterally and distally until the fistula is encountered. A bulb syringe were used to mobilize the vaginal cuff so that the dissection of the vesico-vaginal space and mobilization of the vagina could be performed easily. After adequate dissection and resection of the fistula tract from both the vagina and the bladder, a double-layer closure using 3-0 Vicryl was placed in a interrupted suture to secure the bladder. After the first layer of closure, the bladder was retrograde filled with 300cc of sterile water. Then second layer was closed in the same manner. And a single-layer closure of the vagina using a 1-0 Vicryl was placed transvaginally. After omental interposiotion to the fistula site, the procedure was over. There were no serious intraoperative or postoperative complications. Conclusion Laparoscopic approach for vesicovaginal fistula is safe and feasible.

2048 Colo -Anal Anastomosis: A Novel Idea for Treatment of Re-Re-Recurrent Rectovaginal Fistula

Video Objective Treatment of rectovaginal fistulas was always difficult; treating post radiation recurrent rectovaginal fistulas was challenging; Colo-Anal Anastomosis is a novel way of treating such fistulas. Setting 49yr/Female/P1L1 had undergone Total Abdominal Hysterectomy for AUB-E; was diagnosed with adenocarcinoma of endometrium stage II. Patient underwent BPLND + BSO 3 weeks later and then took 25# radiation for same. Patient developed radiation proctitis and Rectovaginal Fistula following Radiation Therapy. A diversion colostomy was done for same. Patients complaints persisted. Patient then underwent RVF closure with omental flap interposition. Despite the omental flap a distal loopogram was suggestive of leak of dye. Interventions Decision was taken to do a Laparoscopy with Colo Anal Anastomosis. Expected challenges were dense bowel adhesions; deficient anterior rectal wall; Non healing tissue. On Laparoscopy small bowel adhesiolysis was done. Colon was completely mobilized upto splenic flexure so as to obtain a tension free repair. Rectum transected proximal to fistula site. A tunnel was created in the distal rectum. Rectal Mucosa was excised so as to avoid mucus passage. Mobilized bowel was then pulled out through the tunnel. Colon was anastomsed to anal canal perineally by simple interrupted sutures. As anal sphincters were not dissected patient's anal tone was well maintained. Rectal drain was placed. Patient was gradually started on full diet by day 3; rectal drain was removed on day3 post op. Dye study done postoperatively showed no leak of dye. Conclusion Colo Anal Anastomosis is a unique way of treating fistulas not responding to routine RVF repair procedures.

2185 69-Year-Old Male After Gastric Bypass With Choledocholithiasis Treated With EDGE Procedure Complicated by LAMS Dislocation

INTRODUCTION: With the alarming increase in the prevalence of obesity, more people are undergoing bariatric surgeries of which most common is Roux-en-Y gastric bypass (RYGB). This altered anatomy poses challenges in accessing the papilla for ERCP in the setting of biliary pathology. Until recently enteroscopy or surgery assisted ERCP were the two main treatment options. Today, EUS-directed trans-gastric ERCP (EDGE) procedures have emerged as a promising treatment option in such circumstances. CASE DESCRIPTION/METHODS: A 69-year-old male with history of RYGB, cholecystectomy, Barret’s esophagus, CAD and CKD was admitted with one day history of vomiting and RUQ abdominal pain. On initial evaluation the patient was afebrile, normotensive with scleral icterus. Labs were significant for leukocytosis (14.2 10^3/µL), elevated transaminases (AST 254 U/L; ALT 231 U/L) and signs of biliary obstruction (ALP 252 U/L; bilirubin 3.3 mg/dl). Abdominal imaging (CT, US) revealed dilated intra and extra hepatic biliary ducts with the CBD measuring 1.4cm. For further evaluation, an EDGE procedure was performed within 24 hours. After injecting water to form a fluid collection in the stomach and confirming no blood flow in the path, a 20mm Hot Axios LAMS was successfully deployed under EUS guidance. The gastric lumen was confirmed after dilatation to 18mm. The duodenoscope was advanced and subsequent cholangiogram revealed several large stone filling defects along with dilated hepatic ducts. A sphincterotomy was performed, 9-12mm followed by 12-15mm extraction balloons were advanced over the wire and after multiple sweeps, 5 large stones were removed with resolution of biliary obstruction. During the ERCP, the LAMS dislodged into the native stomach over the scope but was able to be successfully removed by rat-tooth forceps. Finally, the fistula was closed using endo-clips and the patient reported resolution of his symptoms and LFTs normalized. DISCUSSION: Choledocholithiasis after RYGB is not unusual as nearly 50% of patients develop biliary stones within two years after surgery. The most common complications after EDGE procedure are bleeding from the fistula site, persistent fistula formation, perforation or adverse events related to ERCP. We present a rare case of LAMS dislocation into the stomach during EDGE which was successfully removed with the snare. Being able to recognize and immediately treat this potential complication may help providers anticipate it during EDGE procedures.

FREE FLOATING RIGHT HEART THROMBI AND PULMONARY EMBOLI: A CASE SERIES

SESSION TITLE: Monday Fellow Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Free floating right heart thrombi (FFRHT) often portend imminent pulmonary embolism (PE) and warrant immediate intervention given their association with high mortality rates - ranging from 27% to 44% with up to 20% mortality within the first day of admission by some reports. Management remains controversial without specific society guidelines, and multiple surgical and pharmacologic treatments have previously been described. Here we present three cases of patients with FFRHT with markedly different management and outcomes. CASE PRESENTATION: Case 1: A 70-year-old man with recent ankle fracture presented with dyspnea and dizziness and was found to have a femoral vein thrombus. Transthoracic echo (TTE) showed right ventricular dilatation and a FFRHT (Fig. 1). He underwent emergent surgical embolectomy with extraction of multiple extensive clots and temporary placement of a right ventricular assist device (RVAD). The patient was later discharged from the hospital with no functional impairment. Case 2: A 74-year-old male dialysis patient presented with fever and pain at his fistula site and received empiric treatment for sepsis. The following day, he developed respiratory failure which progressed to cardiac arrest and underwent six minutes of CPR with ROSC. TTE showed biventricular failure with minimal cardiac activity and a visible RHT (Fig. 2). He received tissue plasminogen activator (tPA) with some improvement on repeat TTE, but soon succumbed to his illness. Case 3: A 49-year-old woman with Hodgkin’s lymphoma and recent left hip replacement presented with dyspnea and calf pain, and was found to have femoral vein thrombosis as well as large bilateral central submassive PE (Fig. 3). Therapeutic anticoagulation was started and TTE showed a large mobile thrombus in the right atrium, which appeared to traverse the inter-atrial septum with a mobile component in the left atrium. She was given tPA and serial repeat TTE showed resolution of RHT and right heart strain. The patient was discharged from the hospital in good condition on oral anticoagulation. DISCUSSION: RHT can be type A "clot in transit” (originating in the periphery) or type B (originating in the right heart). Type A RHT are strongly associated with PE. The existing literature on their management is controversial - while association with PE and high mortality is clear, few reports compare outcomes from anticoagulation alone to thrombolysis or surgical embolectomy (with or without RVAD placement). Incidence of FFRHT is likely drastically underestimated, and is expected to continue rising as bedside cardiac ultrasound becomes more prevalent in the initial assessment of patients with PE. CONCLUSIONS: Bedside cardiac ultrasonography is vital in assessing patients with PE to improve detection of FFRHT. Management of these patients with either thrombolysis or surgical embolectomy should be considered in addition to anticoagulation. Reference #1: Barrios D, Chavant J, Jimenez D, Bertoletti L, Rosa-Salazar V, Muriel A, et al. Treatment of right heart thrombi associated with acute pulmonary embolism. Am J Med. 2017;130:588-595 Reference #2: Koc M, Kostrubiec M, Elikowski W, Meneveau N, Lankeit M, Grifoni S, et al. Outcome of patients in right heart thrombi: the right heart thrombi european registry. Eur Respir J. 2016; 47:869-875 Reference #3: Rose PS, Punjabi NM, Pearse DB. Treatment of right heart thrombo-emboli. 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1690 Management of Non-Malignant Enterocutaneous Fistula Using Fully Covered Stent

INTRODUCTION: Postoperative enterocutaneous fistula (ECF) has a reported prevalence of 3.6% in general surgery, and up to 35% in Crohn disease-related surgery. ECFs can be of low-output, drain < 200 mL/day, or of high-output, drain > 500 mL/day, which unlikely to heal spontaneously. ECFs can cause metabolic disturbances, fluid loss, and malnutrition. CASE DESCRIPTION/METHODS: Case 1: A 54-year-old man with a history of colonic transmural necrosis status post multiple surgeries and end transverse colostomy placement, presented with a two-week history of passing stool from the lateral aspect of his peristomal incision, consistent with enterocutaneous fistula. The 2 fistulae ends were seen on the skin, laterally to the stoma (Figure 2c), and both other ends were identified in the stoma lumen. CT fistulogram confirmed the fistulae. After advancing the endoscope into the stoma, a 2 cm friable stenosis was seen (Figure 1a). The fistulae tracts were treated with silver nitrate and were injected with fibrin glue. A 20 mm × 6 cm fully-covered stent was placed (Figure 1b) and sutured in place. A month later the fistulae had healed (Figure 2d), with no recurrence reported. Case 2: A 64-year-old man with a history of metastatic mucinous appendiceal cancer status post multiple abdominal surgeries, referred for his recurrent ECF. CT scan showed air tracking outside the colon at the level of the cutaneous fistula site. Water-soluble contrast pushed through the rectum showed an occlusion with contrast extravasation is seen in the fistula (Figure 3e). Sigmoidoscopy confirmed the site of obstruction and the area of leakage. A fully covered stent was placed to relieve the obstruction and cover the fistula (Figure 3f). Initially, the fistula output resolved, but when the stent was removed a month later, the fistula output returned. So, a stent was placed again and was sutured to the colon. The patient is now asymptomatic and having normal bowel movements. DISCUSSION: ECF can cause significant morbidity and affect the quality of life. Surgical repair of ECF has a recurrence rate as high as 36% and is associated with high mortality especially in malnourished patients. Thus, endoscopic intervention using fully-covered stents can be helpful in healing the fistulae. In these 2 cases, the placement of a fully-covered stent relieved the coexisting obstruction, diverted the flow away from the fistula, and simultaneously covered the fistula end. The patients experienced relief of fistula symptoms and avoided them major surgical intervention. Watch the video: http://bit.ly/30BIvtw.

1575 Colouterine Fistula: A Rare Crohn's Complication

INTRODUCTION: Colouterine fistulas are a rare complication of gastrointestinal diseases, mostly described as a complication of diverticulitis in elderly patients. Colouterine fistula as a complication of Crohn's disease is exceptionally rare. We present a young Caucasian female with history of poorly controlled Crohn's disease presenting with colouterine fistula. CASE DESCRIPTION/METHODS: 26-year-old Caucasian female with ileal Crohn's disease since 2014 presented with abdominal pain and fever. Her PMH was significant for poor compliance with medications and follow ups. In the preceding 6 months she had a complicated clinical course including a flare with SBO and intraabdominal abscess while she was 23 weeks pregnant needing resection of TI and cecum with a diverting ileostomy followed 2 weeks later by a miscarriage, drainage of a perirectal abscess, fistula between loops of small bowel, and ileostomy take down followed by an abdominal wall abscess needing drainage. She had been lost to follow up and had not been on any medications the preceding one year. Her last colonoscopy was prior to ileostomy take down and had shown healthy appearing ascending colon stump, mild erythematous mucosa throughout the colon with no pathologic evidence of Crohn's and a well healing perianal fistula site. At presentation, ESR was 70 mm/h and CRP 81 mg/L. CT abdomen was read as a large peripherally enhancing fluid collection within the right lower abdomen and pelvis and mildly thickened neoterminal ileum. An abscessogram however showed the fluid collection was a large colouterine fistula filling the ascending colon at the anastomosis and both Fallopian tubes. Patient has been started on induction therapy with adalimumab and discharged with slow prednisone taper with plans to follow up for continued adalimumab therapy as well as evaluation at a facility with specialty Uro-Gynecology resources for fistula correction. DISCUSSION: Fistulas between small bowel and uterus in Crohn's disease has been described in literature. Fistulas between colon and uterus in Crohn's disease is exceptionally rare; to date only two cases have been reported, a sigmoid colouterine fistula and rectouterine fistula. The thick uterine wall is considered to be a protective factor against fistula formation, but prior colonic surgery or disruption of uterine wall integrity may predispose to fistula formation in Crohn's disease. Our patient had a recent ileocecectomy which was likely contributory to colouterine fistulization in the setting of poor compliance.

1606 A Very Unusual Case of Colonic Adenocarcinoma Originating From an Enterocutaneous Fistula

INTRODUCTION: Enterocutaneous fistulas are a well known sequelae of intrabdominal surgeries. Common complications of these fistulas include sepsis, electrolyte abnormalities, and nutritional deficiencies. We present an unusual case of a mucinous colonic adenocarcinoma originating from an enterocutaneous fistula. To our knowledge, there are no other known cases of colonic adenocarcinoma originating from an enterocutaneous fistula. CASE DESCRIPTION/METHODS: Patient was a 65-year-old male with a past medical history significant for Korsakoff dementia and OLT ten years ago who presented to GI clinic. He had complaints of weight loss, decreased appetite, and increased lethargy. The patient had an enterocutaneous fistula as a result of a bowel resection following perforation from ERCP nine years prior. The fistula was never repaired as the patient was thought to be a poor surgical candidate and it did not seem to interfere with his quality of life. Physical exam was notable for a tender abdomen with several scattered erythematous and excoriated lesions. There was an ostomy bag covering a 10cm fungating, necrotic appearing, malodorous mass with greenish liquid in the ostomy bag (Figure 1). This was surrounding the fistula site. Based on CT abdomen results from six months prior, it was suspected that this was an enterocutaneous fistula that may connect to the transverse colon. Biopsies were taken at bedside which revealed mucinous moderately differentiated adenocarcinoma, morphologically suspicious for colonic-type adenocarcinoma (Figure 2). Repeat CT abdomen showed a large heterogeneous abdominal wall lesion and mild wall thickening of adjacent mid-transverse colon consistent with the known mass. DISCUSSION: The prevalence of enterocutaneous fistulas in the population is not known; most are iatrogenic or postoperative in etiology (75-85%), with the ileum being the most common location. This patient’s enterocutaneous fistula was never repaired and was likely the result of a bowel resection following perforation from ERCP several years prior. As with chronic inflammatory states, such as that seen in IBD which can predispose to colorectal cancer, we hypothesize that a similar mechanism of chronic inflammation from a fistula connection to the outside environment may have contributed to this patient developing a colonic malignancy, especially in the setting of his immunosuppression. Furthermore, in patients who are unable to undergo repair of enterocutaneous fistulas, their risk of colorectal cancer may be increased.

FISTULA LASER ABLATION FOR ANAL FISTULAS (systematic review)

AIM: to reveal fistula healing incidence after application of FiLaC™ technique and factors that can affect it. MATERIALS AND METHODS: when searching electronic medical databases for publications that evaluated the results of the FiLaC™ technique in the treatment of anal fistula, 6 studies were selected, corresponding to the search queries. The search was carried out taking into account the principles of systematic literature reviews and meta-analyses (PRISMA). The time interval for searching publications was between 2011 and October 2018. In the publications included in the analysis, the following parameters were evaluated: general characteristics of the study groups, technical aspects of the FiLaC™ technique, the site of the fistula in relation to the anal sphincter, the option of closing the internal fistula, the incidence of healing and recurrence of fistula, the duration of the follow-up period after surgery, re-operated cases of fistula recurrences. RESULTS: taking into account the data obtained in the analysis of the selected studies, the mean incidence of fistula healing was 64.5% (40.0-88.2)%. It was found that the only factors that can be used to assess their impact on the incidence of fistula healing were: the gender and the variant of the fistula site in relationship to the anal sphincter (transsphincteric/extrasphincteric). Statistical analysis and evaluation of the odds ratio revealed no effect on the treatment result of the above parameters. CONCLUSION: the analysis of the data showed that FiLaCis mainly indicated for the treatment of patients with extrasphincter and transsphincteric anal fistulas. The method can be recommended as a sphincter-sparing treatment in patients with initially weakened anal sphincter function and, consequently, with a high risk of anal sphincter insufficiency in the application of traditional techniques. Further evaluation of the treatment results in the treated period and their comparison with the results after other variants of coagulation of the fistula walls is required to obtain a clearer understanding of the effectiveness of the FiLAC technique.

Sotatercept Safety and Effects on Hemoglobin, Bone, and Vascular Calcification

IntroductionPatients with end-stage kidney disease (ESKD) exhibit anemia, chronic kidney disease‒mineral bone disorder (CKD–MBD), and cardiovascular disease. The REN-001 and REN-002 phase II, multicenter, randomized studies examined safety, tolerability, and effects of sotatercept, an ActRIIA-IgG1 fusion protein trap, on hemoglobin concentration; REN-001 also explored effects on bone mineral density (BMD) and abdominal aortic vascular calcification.MethodsForty-three patients were treated in REN-001 (dose range: sotatercept 0.3‒0.7 mg/kg or placebo subcutaneously [s.c.] for 200 days) and 50 in REN-002 (dose range: 0.1‒0.4 mg/kg i.v. and 0.13‒0.5 mg/kg s.c. for 99 days).ResultsIn REN-001, frequency of achieving target hemoglobin response (>10 g/dl [6.21 mmol/l]) with sotatercept was dose-related and greater than placebo (0.3 mg/kg: 33.3%; 0.5 mg/kg: 62.5%; 0.7 mg/kg: 77.8%; 0.7 mg/kg [doses 1 and 2]/0.4 mg/kg [doses 3‒15]: 33.3%; placebo: 27.3%). REN-002 hemoglobin findings were similar (i.v.: 16.7%−57.1%; s.c.: 11.1%‒42.9%). Dose-related achievement of ≥2% increase in femoral neck cortical BMD was seen among only REN-001 patients receiving sotatercept (0.3‒0.7 mg/kg: 20.0%‒57.1%; placebo: 0.0%). Abdominal aortic vascular calcification was slowed in a dose-related manner, with a ≤15% increase in Agatston score achieved by more REN-001 sotatercept versus placebo patients (60%‒100% vs. 16.7%). The most common adverse events during treatment were hypertension, muscle spasm, headache, arteriovenous fistula site complication, and influenza observed in both treatment and placebo groups.ConclusionIn patients with ESKD, sotatercept exhibited a favorable safety profile and was associated with trends in dose-related slowing of vascular calcification. Less-consistent trends in improved hemoglobin concentration and BMD were observed.

Laparoscopic transvesical vesicovaginal fistula repair with the least invasive way: Only three trocars and a limited posterior cystotomy

ObjectiveTwo conventional approaches for vesicovaginal fistula (VVF) repair are transabdominal repair for supratrigonal VVF and transvaginal approach for low lying fistulae. Laparoscopic surgery was introduced to duplicate the surgical steps of the transabdominal approach with reduction in morbidity. We report a series of patients treated with a modified laparoscopic technique which includes the use of only three trocars and a limited posterior cystotomy. MethodsWe retrospectively reviewed the data of eight patients who underwent laparoscopic VVF repair with our standardized technique from January 2015 to April 2018. Only cases with a supratrigonal fistula were included. We constantly used only three trocars. A limited 2 cm midline posterior cystotomy was performed using ultrasonic energy. A stay suture on a straight needle was passed percutaneously in the abdomen, then on either side of the cystotomy and finally was exteriorized to maintain countertraction. The cystotomy was extended downwards to include the fistula site. The fistula was dissected circumferentially to raise the bladder and vaginal flaps. The vaginal defect was closed in a transverse fashion and the cystotomy was closed vertically. ResultsMean operative time was 178±31.6 min and estimated blood loss was 60±18.7 mL. Flap interposition was performed in six cases. No intraoperative complications were recorded. Mean hospital stay was 2.25±0.89 days. During hospitalization two patients experienced postoperative complications (Clavien grade I). Mean follow-up was 20.9±11.1 months (6.0–39.0 months). All patients remained continent during the follow-up period. ConclusionsThis minimally invasive laparoscopic approach with only three trocars and limited posterior cystotomy provides excellent results with minimum morbidity.

DOZ047.10: Acquired tracheoesophageal fistulas after esophageal atresia repair

Abstract Aim Tracheoesophageal fistula (TEF) recurrence is a frequent but challenging complication after esophageal atresia (EA) repair. Although most recurrent TEFs are commonly seen at the original fistula site, long new fistulas localized differently from the congenital TEF sites are called acquired TEFs (acq-TEF). Acq-TEFs are long new fistulas with unusual locations, including fistulas from the esophagus to anywhere on the airway such as the bronchus, trachea, or lung parenchyma. Herein, we aimed to discuss diagnostic and management challenges in different localizations of acquired TEF. Methods The medical records of patients admitted with acq-TEF in the last 5 years were retrospectively evaluated. The demographic features, admission complaints, physical and radiological findings, TEF localization and management were recorded. Results From 16 TEF recurrences, 4 TEFs were acquired fistulas. Admission age ranged from 3 months to 8 years. The female/male ratio was 2/2. The complaints were recurrent respiratory tract infections, choking, and coughing in all cases. Three of the cases had proximal EA + distal TEF; the other case was isolated EA. Primary repair was performed in 3 cases and colon interposition was performed in 1 case. Anastomotic leak and mediastinitis after initial operation were seen in 3 cases. Three acq-TEFs were to the cervical part of the trachea, one was from the colon conduit to the trachea, one was to right bronchus by passing through the intrathoracic abscess cavity, and one was directly to the right bronchus. In all cases the TEFs were shown in sine-esophagography and confirmed with bronchoscopy during operation. TEF was repaired by thoracotomy incision in 3 cases and callor incision in 1 case. The second acq-TEF of Case 1 was closed spontaneously. Muscle flap or pleura was placed between suture lines in all cases. All TEFs were confirmed to be closed with esophagography in all cases at postoperative period. Conclusion Acq-TEF is mostly seen secondary to local or diffuse mediastinitis. Besides its classical location of TEF, acq-TEFs may be seen at unusual rare localizations such as esophagus to right bronchus, esophagus to abscess cavity, and conduit to trachea. They cause both diagnostic and surgical challenge. Clinicians should be aware of these different localizations of Acq-TEFs in order to evaluate and manage these patients more comprehensively.

Coil Embolization of an Iatrogenic Arteriovenous Fistula between the Superior Mesenteric Artery and Vein: A Case Report

Superior mesenteric arteriovenous fistulae are rare. A 32-year-old woman presented with abdominal pain. The angiography showed that the superior mesenteric vein was aneurysmal. The patient underwent coil embolization, during which a balloon catheter was inflated before the fistula for the protection of coil migration with a high blood flow. After the balloon inflation, one 8-mm and two 7-mm coils were deployed at the fistula site. The final angiography showed successful embolization with no visualization of the fistula and the aneurysmal vein.