Fistulous Opening Research Articles

Unexpected cause of upper gastrointestinal bleeding: beyond the typical complications of gallstone disease.

An 88-year-old man presented with haematemesis with haemodynamic stability requiring transfusion of 5 units of blood. Physical examination was unremarkable. Upper endoscopy identified a fistulous opening in the proximal second part of the duodenum (D2) with an oozing bleed and blood clots. A computed tomography (CT)-angiogram revealed a 18mm cystic artery pseudoaneurysm next to a fistulous communication between the gallbladder and D2, allowing the passage of a large stone (Bouveret syndrome). The patient successfully underwent emergent arterial embolization guided by a clip endoscopically-placed near the duodenal fistulous orifice. There were no intercurrences or bleeding recurrence.

Our experience in the treatment of congenital nasal median heterotopias in children and an overview of various treatment tactics

Yo consider the clinical picture, methods of radiation diagnosis and to study the surgical results of a dermoid cyst of the nose according to the literature. A retrospective review of medical histories with the diagnosis of "Dermoid cyst of the back of the nose and nasal cavity, epidermal cyst of the back of the nose, glioma, encephalocele" was conducted from 2017 to 2022 in the Pediatric Otorhinolaryngological Department of the National Medical Research Center for Otorhinolaryngology of the Federal Medical-Biological Agency of Russia. The case histories were analyzed by the nature of the lesion, the imaging techniques performed, the course of the operation and the results obtained. A total of 16 medical histories were analyzed, the average age was 4.5 years (range 10 months - 15 years), over the past 5 years with a diagnosis of "Dermoid cyst of the nasal dorsum and nasal cavity, glioma, epidermal cyst of the nasal dorsum, encephalocele". All patients underwent magnetic resonance imaging (MRI) in the preoperative period, 14 patients also underwent computed tomography (CT). Of these, 7 had a confirmed dermoid cyst with a fistula, 3 patients without a fistula, 3 patients had glioma, and 1 had encephalocele, 2 patients had an epidermoid cyst. A fistulous opening of the dermoid cyst of the nasal dorsum and nasal cavity was observed in the upper third of the nasal dorsum in 3 children, in the middle third in 2 patients and in the lower third in 2 children. The article presents a scheme for the characteristics of the lesion and the tactics of surgical treatment in comparison with the data of foreign authors. Intraoperatively, intracranial spread occurred in 6 patients. Various surgical approaches for intracranial proliferation and a corresponding literature review are also presented. Catamnestic follow-up ranged from 1 to 5 years (on average, 3.5 years), no relapses or postoperative complications were noted. Nasal median heterotopias are a rare congenital anomaly. Preoperative preparation should include CT and MRI to assess the lesion and exclude intracranial spread. The surgical approach depended directly on the localization of heterotopia and its spread. All patients had a good cosmetic result after the surgical treatment performed by us according to the author's method.

Intestinal Tuberculosis with Enterocutaneus Fistula: A Rare Case

Introduction: Enterocutaneous fistula is a common postoperative complication. The incidence of enterocutaneous fistula as a complication of intestinal tuberculosis is quite rare, so we are interested in reporting this case. Case Report: 32-year-old male presented with history of abdominal pain and fecal matter coming out from an opening in umbilical region for the past 1 month. Patient have history of laparotomy exploration 7 months ago and histopathology showed intestinal tuberculosis. Currently, patient was undergoing TB treatment with anti-tubercular treatment (ATT) for the seventh month. Physical examination showed fistulous opening 2x2 cm over the scar of previous laparotomy. Laboratory examination revealed leukocytosis shift to the left and hypoalbuminemia. Chest X-ray showed active pulmonary tuberculosis. Abdominal CT with with contrast showed localized ileus consist of sentinel loop and suggestive intestinal tuberculosis. Diagnosis of tubercular enterocutaneus fistula arising of as a post-operative complication was made. Patient was given intravenous fluids, antibiotics, antitubercular treatment, and wound care. Patient responded well to conservative management. Discussion: Intestinal tuberculosis (TB) is the sixth most common site of extrapulmonary tuberculosis which can occur primary or secondary. Enterocutaneus fistula (ECF) is a rare complication of intestinal TB and can be managed based on whether the output is low or high. Conservative management can be done through administration of intravenous fluids, antibiotics, antitubercular treatment, and wound care

Sigmoido-vesical fistula secondary to hernia mesh migration; a long-term rare complication of laparoscopic transabdominal preperitoneal inguinal hernia repair

A 47-year old male presented with frequent urinary tract infections (UTIs), hematuria and pneumaturia with a past history of laparoscopic bilateral inguinal hernia repair 5 years ago. Ultrasonography (USG) and contrast enhanced computed tomography did not furnish any evidence to arrive at a diagnosis, interestingly, cystoscopy revealed a mesh in the urinary bladder making apparent the diagnosis of Sigmoido-vesical fistula secondary to mesh migration. Later, surgical removal of the mesh from the sigmoid colon and urinary bladder with rent closure of the fistulous opening was done successfully. Our case thus, highlights the long-term rare complication of transabdominal preperitoneal (TAPP) surgery.

Complete Second Branchial Cleft Fistulas: A Clinicosurgical Experience.

A complete second branchial fistula is very rare and has an internal opening at the tonsillar fossa and an external opening at the lower third of the sternocleidomastoid (SCM). Patients commonly present with persistent or intermittent mucoid or mucopurulent discharge from an external opening. The diagnosis is most often clinical and radiological investigations are rarely needed. Treatment of choice is complete surgical excision. The aim of this article is to aware young ENT surgeons of the various clinical and intraoperative surgical findings that can be encountered while dealing with these cases. This observational study was done for a period of 10years. A total of 20 cases of fistula were included which intraoperatively had a complete track from tonsillar fossa to neck. Excision of the tract was carried out via combined transcervical and transoral approach under general anaesthesia using two incisions in stepladder pattern. Each patient was seen after one year of surgery to assess for any recurrence. Different findings of patients including age/sex at surgery, initial presentation, family history, laterality of the fistula tract, Intraoperative surgical findings, complications, and recurrences. were noted. Of the 20 patients, 13 (65%) were females and 7 (35%) were Females. Most common complaint was fistulous opening with intermittent discharge(15patients; 75%).Branchial cleft fistulae more commonly affected the right neck (14 patients, 78%) among unilateral cases and 2 patients (10%) had bilateral fistulae. No patient had associated congenital anomaly/syndrome, family history or and visible opening in tonsillar area. Glossopharyngeal nerve was identified in 12 cases and track was seen passing lateral to it except in one case. The internal opening of track was seen over posterior tonsillar pillar in 15 cases (75%) while in 5 patient the track was seen entering tonsillar tissue or bed. Tonsillectomy was done in 5 cases while not done in 15 cases where track was seen entering posterior pillar. All patients were seen at one year follow up. No recurrence was seen at one year of follow up. Complete second branchial cleft fistulae are rare. They are usually right sided and unilateral. The track passes between carotid bifurcation and invariably passes lateral to both glossopharyngeal and hypoglossal nerves. Track usually ends at the posterior tonsillar pillar. Tonsillectomy is not routinely indicated. Recurrences are not typically seen.

A Rare Case of Urethral Tuberculosis

Urethral tuberculosis is a rare disease since the advent of highly effective anti-tuberculosis drugs. The article describes an extremely rare clinical observation of a 34-year-old patient with the transition of tuberculous inflammation from the subcutaneous tissue to the wall of the urethra with intact kidneys. Since the first blood discharge from the urethra, the diagnostic process took 3.5 years, all these years, multiple examinations for tuberculosis were carried out and the results were negative, while the disease progressed. The diagnosis was differentiated between acute purulent anterior subcutaneous paraproctitis and festering pararectal cyst. There were repeated openings of the perineal abscess, no bacterial growth was observed, histological tests revealed chronic purulent inflammation. In view of the persistent recurrent course of perineal abscess, tuberculosis was repeatedly suspected. Acid-resistant mycobacteria were found in the discharge from the fistula by fluorescent microscopy: 10-99 in the sample. Tuberculous mycobacteria were not found in the urine by polymerase chain reaction. The patient was diagnosed with A18.4. Tuberculosis of subcutaneous fat (perineum). Mycobacterium tuberculosis (+). The course of disease was complicated by perineal fistula. With the anti-tuberculosis treatment, the fistulous opening healed within a month.

Robotic-Assisted Laparoscopic Repair of Iatrogenic Vesico-Vaginal Fistula

<h3>Study Objective</h3> This video highlights the principles of robotic assisted laparoscopic repair of iatrogenic vesico-vaginal fistula <h3>Design</h3> Surgical video presentation. <h3>Setting</h3> Academic tertiary care center. <h3>Patients or Participants</h3> We present 2 cases of iatrogenic vesico-vaginal fistula repaired robotically. Case 1 is a 49-year-old patient with a vesico-vaginal fistula after an open supracervical hysterectomy with incidental cystotomy and repair. Case 2 is a 61-year-old patient who was referred for management of a supra-trigonal vesico-vaginal fistula as a complication of vaginal hysterectomy. <h3>Interventions</h3> Case 1 started with cystoscopy and placement of ureteral stents. The peritoneum above the vaginal cuff was incised and an anterior colpotomy was created. The bladder was dissected until the fistula was identified and the injured area was 4 cm away from the colpotomy. The fistulous margins where dissected. The bladder mucosa was repaired in 2 layers in a running fashion. The bladder was retrogradely filled, confirming the repair was watertight. The colpotomy was closed in 2 layers. The repair was reinforced with omental interposition. For case 2, a stent was placed through the vaginal fistulous opening. The stent was identified transvesically with cystoscopy. Bilateral ureteral stents were placed. Similar steps from case 1 were carried out. Cystoscopy was performed confirming an adequate repair. Bilateral ureteral stents were removed. A Foley catheter was inserted to remain in place for 3 weeks. <h3>Measurements and Main Results</h3> Both patients were discharged on post-operative day 1. The patient in case 1 had a voiding cystogram showing no evidence of residual or recurrent fistula on post-operative week 3, and urine leakage was resolved. The patient in case 2 is scheduled for follow up on post-operative week 3. <h3>Conclusion</h3> Robotic assisted repair offers optimal surgical exposure and is ideal for supra-trigonal and complex vesico-vaginal fistulas, affording good outcomes for patients.

S2280 Benign Bronchoesophageal Fistula Recalcitrant to Endoscopic Management

Introduction: The management of bronchoesophageal fistulas (BEFs) can be challenging and often requires a multidisciplinary approach. We present the case of a spontaneous BEF that defied multiple endoscopic attempts at closure. Case Description/Methods: A 69-year-old malnourished woman with heavy tobacco use and chronic obstructive pulmonary disease presented with cough incited by food intake and pneumonia. Fluoroscopic contrast study highlighted a bronchoesophageal fistula with opacification of the left mainstem bronchus (Figure). An initial upper endoscopy demonstrated a small recess but without an obvious fistulous opening at 29 cm from the incisors and without malignancy on biopsy. A subcarinal 2.3 cm broncholith seen on a chest CT performed 2 years prior was now noticeably absent, suggesting broncholith erosion as the cause of the BEF. An attempt at endoscopic closure was recommended by multidisciplinary consensus. Since the fistulous opening was not readily identifiable at initial endoscopy, a combined bronchoscopic-endoscopic procedure was performed with bronchoscopic passage of a guidewire through the fistula tract into the esophagus. Once localized, abrasion of the fistula orifice with argon plasma coagulation followed by over-the-scope clip (OTSC) closure was performed. Symptom and radiographic recurrence at 2 weeks from migration of the OTSC resulted in uneventful endoscopic removal of the OTSC. Subsequent placement of a fully covered self-expandable metal stent with endoscopic suture fixation resulted in intolerable chest pain despite narcotic administration and incomplete sealing of the fistula on radiographic imaging, necessitating stent removal one week later. A third attempt at endoscopic suture closure of the fistula was unsuccessful. A PEG-J feeding tube was placed for enteral nutrition as well as a retrograde pigtail drainage catheter fitted through the PEG to manage secretions at and above the BEF. Definitive surgical repair will be considered once her nutritional status is optimized. Discussion: Despite publications of successful endoscopic closure of benign BEFs, a significant proportion of these cases do not respond to endoscopic interventions and are not likely to be reported in the literature (reporting bias). Benign BEFs should be managed in a multidisciplinary fashion and alternative treatment strategies pursued when endoscopic therapies are deemed unsuitable or fail at closing the fistula.Figure 1.: Esophagram highlighting bronchoesophageal fistula. Esophagus (blue arrows); left mainstem bronchi (red arrows).

S1783 Noncirrhotic Portal Hypertension and Pancreaticogastric Fistula Complicating Acute Pancreatitis With Fluid Collections

Introduction: Noncirrhotic portal hypertension constitutes an increase in pressure of the portal venous system in the absence of cirrhosis. This is a rare condition; however, it is insufficiently acknowledged given its decreased prevalence in North America and Europe compared to other nations. We present a rare case of noncirrhotic portal hypertension and pancreatico-gastric fistula complicating acute pancreatitis with an acute fluid collection and resultant portal vein narrowing. Case Description/Methods: A 55-year-old man with history of alcohol use disorder presented to the emergency department with worsening abdominal pain 2 weeks after discharge for uncomplicated acute pancreatitis. Lipase was 48 IU/L (normal 11-82 IU/L). CT abdomen showed increasing peripancreatic fluid collection with marked narrowing of the main portal vein, which appeared near threadlike, and narrowing of the bifurcation of the portal vein extending into the left portal vein. The splenic vein was also severely narrowed (Figure A). He was discharged home with outpatient follow-up, however, returned to the ED for intractable pain one month later. A CT abdomen showed florid changes of pancreatitis with pseudocyst formation with new foci of air within the collection concerning for fistulous tract formation with the gastric lumen (Figure B). The portal vein and splenic vein narrowing improved, but the narrowing of the right and left portal veins worsened. He underwent upper endoscopy which showed a small area of White "milky" base in the posterior wall of the incisura angularis which was suggestive of fistulous opening in the area (Figure C). Four columns of small distal esophageal varices were also noted. During admission, paracentesis was performed for ascites. Serum ascites albumin gradient was over 1.1 consistent with ascites due to portal hypertension – likely due to the portal vein narrowing. Patient was discharged in stable, improved condition. Discussion: Although portal hypertension normally presents in cirrhotic patients, it may rarely present in the absence of cirrhosis by conditions such as portal vein thrombosis or portosinusoidal vascular disease. Compression of the portal vein from an acute pancreatic fluid collection is an extremely rare cause of noncirrhotic portal hypertension. Clinicians should have a high index of suspicion for complications related to portal hypertension such as ascites or varices in patients with a prolonged course of acute pancreatitis without cirrhosis.Figure 1.: (A) Contrast CT abdomen showing marked narrowing of the main portal vein, which appears near threadlike. (B) One of 2 foci of air in the collection at the anterior superior aspect of the pancreatic body. Appears inseparable from the posterior wall of the gastric body, concerning for fistulous involvement. (C) Area of White “milky” base in the posterior wall of the incisura angularis. This area was rinsed, however re-accumulated despite no obvious opening seen.

Successful Closure of a Rare Cause of Tracheoesophageal Fistula Using an Over-the-Scope Clip.

CASE REPORT A 27-year-old man with an accidental bullet injury to his neck was tracheostomized for prolonged mechanical ventilation and had multiple complications including right hemothorax and a bullet lodged in the subhepatic space. He was tracheostomized for 12 weeks. On restarting of oral feeds, he complained of persistent cough, aggravated by meal intake. A tracheoesophageal fistula (TEF) was suspected, probably due to the bullet injury/prolonged tracheostomy. Upper gastrointestinal endoscopy revealed TEF of size 15 mm with smooth margins at 25 cm from the incisors (Figure 1). After due discussion, endoscopic closure was decided. The margins of the defect were freshened with argon plasma coagulation to facilitate healing (Figure 1). An over-the-scope clip was placed over the fistula site (Figure 2) (size 11/6t; OVESCO Endoscopy, Tuebingen, Germany) to close it. There were no procedure-related complications. He was started on oral feeds 24 hours after the procedure. A follow-up upper gastrointestinal endoscopy 3 weeks later revealed healing of the fistula site (Figure 3). On the 24-month follow-up, he is doing fine.Figure 1.: Endoscopic images showing fistula with smooth edges (A) and the edges freshened with argon plasma coagulation (B).Figure 2.: Fistulous opening closed with OVESCO (A), and the chest x-ray image showing the over‐the‐scope clip (arrow) and impacted bullet (arrow head) (B).Figure 3.: Follow-up endoscopy image showing the healed fistulous site with over‐the‐scope clip in situ.There are multiple devices for the endoscopic management of TEF,1 and the use of an over-the-scope clip has a technical success of 87.5%.2 Freshening the edges of chronic TEF by argon plasma coagulation increases the technical success.2 DISCLOSURES Author contributions: N. Kumar: data collection, video editing, and manuscript writing. A. Sachan: data collection and manuscript writing. G. Muktesh: review of the manuscript and video. R. Kochhar: review of the manuscript and video. J. Samanta: data collection, video editing, and manuscript writing, and is the article guarantor. Financial disclosure: None to report. Informed consent was obtained for this case report.

Experience in the use of low-temperature plasma in the therapy of radiation reactions.

The use of low-temperature plasma is a modern and developing direction in medicine, including rehabilitation. Low-temperature plasma (LTP) has a high antiseptic, wound-healing activity, and is also a safe method of physical exposure. In the in-patient facility of clinical unit of Federal State Budgetary Educational Institution of Further Professional Education Russian Medical Academy of Continuous Professional Education of the Ministry of Healthcare of the Russian Federation named after Prof. Yu.N. Kasatkinа, a patient was treated with low-temperature argon plasma after selective right cervical lymph node dissection, resection of the mandible, and tissues of the oral floor with defect plasty with a fibular autograft for cancer of the gingival mucosa of the mandible on the right pT4aN0M0, stage IVa. In the process of EBRT (external beam radiation therapy), the patient developed a complication in the form of a local radiation reaction with the formation of a fistulous opening in the area of the postoperative scar. The fistulous opening and the affected area were treated with a cooled air-plasma flow. During the continued use of LTP, the termination of pyorrhea, a decrease in hyperemia and edema in the area of tissues damaged by ionizing radiation were noted. The patient was promptly continued radiation therapy.&#x0D; Thus, the use of this therapeutic factor in the program of medical rehabilitation is an effective way of local impact on the pathological focus, allows you to achieve a quick reparative effect, eliminates and prevents the development of bacterial complications. In addition, the use of an air-plasma flow contributes to the rapid relief of manifestations of radiation reactions, having a beneficial effect on damaged tissues, as well as shortening the rehabilitation period for severe cancer patients in the postoperative period and during the course of EBRT. The results of LTP action have a positive effect on the general condition of patients and improve their quality of life.

Unilateral Tb Epididymo-Orchitis with Scrotal Fistula- A Case Report

Tuberculosis is one of the most common worldwide diseases that remain almost unaltered in prevalence for the past few years. Genitourinary tract tuberculosis is common, but when associated with scrotal fistula it is a rare presentation. A 50 years old male came to the hospital with the complaints of pricking pain and swelling in the left side of scrotum for the past 2 months. He had history of smoking for past 40 years, on examination swelling of size approximately 6x5 cm present in left side of scrotum, globular in shape; penis pushed to right side was present, lower part of the swelling was firm to hard in consistency, left cord thickness was present and fixity to skin was also present. There was a small fistulous opening present in the left side of scrotum with no active discharge. Bilateral inguinal lymph nodes were palpable. This is a rare case presentation of tuberculous epididymo-orchitis with scrotal fistula leading to testis removal. Initially emperical treatment was started for TB epididymoorchitis which turned unresponsive, so he was then proceeded for surgery to avoid further disease progression. This case was managed radiologically, clinically and pathologically. This case report shows how the case was managed and followed up.Since symptoms of TB epididymo-orchitis are milder when compared to the symptoms of pyogenic epididymo-orchitis, they appear to physicians in later advanced stages. Tuberculosis should be considered in Patients with mild symptoms of epididymo-orchitis, mainly in those with HIV, immunosuppressive conditions and endemic areas.

Colorectal carcinoma presenting as spontaneous colocutaneous fistula - A rare case report and review of literature.

Introduction and importanceColon cancer presenting as spontaneous enterocutaneous fistula are rare with only few cases reported in the literature. Such presentation signifies locally advanced disease with poorer outcomes. Enterocutaneous fistula increases morbidity and mortality in cancer and may potentially delay the definitive care. It poses a difficulty in management in terms of patient optimization, determining the type of resection (palliative or curative) and the operative timeline.Case presentationA 47 years old female presented with complaints of foul smelling discharge from a fistulous opening in right iliac fossa with occasional per rectal bleeding for the past six months. Imaging showed ascending colon mass breaching the peritoneum with fistulous tract opening into subcutaneous plane. Exploratory laparotomy with extended right hemicolectomy and en bloc resection was performed.Clinical discussionCutaneous fistula can be caused by traumatic, postoperative etiologies and about 20 % are of spontaneous etiologies. Colon cancer has the ability to mimic any abdominal disease with a wide spectrum of presentations. The locoregional extension from the bowel creates a passage of colonic contents to evacuate from the external opening. The fistulous tract of colon cancer is less likely to close spontaneously and may require surgical intervention following appropriate resuscitation. Due to features suggestive of bowel obstruction an early single stage surgery was performed in our case.ConclusionThere are no existing guidelines for colon cancer with colocutaneous fistula because they are the same for benign fistulas (resuscitation, control of output, eradication of the infection, nutritional optimization, surgery) along with a multidisciplinary oncology team approach.

A case of successful treatment of tracheoesophageal fistula using laser exposure

The study objective – to present a unique clinical observation of the successful treatment of tracheoesophageal fistula using laser exposure.Case report. Patient H., 51 years old, applied to the Moscow City Oncology Hospital No 62, Moscow Healthсare Department on January 22, 2018, with a diagnosis of thyroid cancer (multicentric growth), T3N0M0 (hospital No. 1974 / 43). Thyroidectomy was performed on 03.08.2009, removal of a recurrent tumor with resection of the esophageal wall and trachea – 03.02.2021. Histological examination No. 5589 / 56662–56668 dated 09.02.2021: papillary cancer with invasion of the wall of the esophagus and trachea. Resection within unaltered tissues. A mobilized sternocleidomastoid muscle was used to separate the esophagus and trachea. A nasogastric tube was used for 14 days. The wound on the neck healed by primary intention. The patient began to eat through the mouth. A day after the removal of the probe, facial emphysema began to grow intensively, which was accompanied by a cough. The nasogastric tube is reinserted. With fluoroscopy of the esophagus and with pharyngogastroduodenoscopy, a tracheoesophageal fistula was revealed along the right lateral wall of the trachea, about 0.5 cm in size, 1.5–2 cm below the level of the vocal folds. On endoscopic examination a week later, the fistula was already 1.0 cm in size. Conservative therapy and surgical treatment were carried out. Due to the flexible laser fiber, a phased effect on the fistula wall was carried out, both from the esophagus and from the trachea. Within a week after the first session, the fistulous opening decreased by 2 times. Then 2 more sessions were carried out with an interval of 10 days. During endoscopic examination from 05.05.2021 the fistula between the trachea and the esophagus is not defined. The mucous membrane is epithelized, smooth. Swallowing is free.Conclusion. Thus, the problem of treating patients with tracheoesophageal fistulas is extremely complex and versatile. The localization of the fistula, its size, and the clinic’s capabilities for treating a patient are of great importance.

Mirizzi Syndrome With Bouveret Syndrome: A Rare Amalgam

Mirizzi and Bouveret syndromes are uncommon but important complications of calculous cholecystitis. Mirizzi syndrome commonly presents with jaundice due to extrinsic compression on the common bile duct by an impacted stone at the gall bladder infundibulum, whereas Bouveret syndrome presents with gastric outlet obstruction due to a large stone in the duodenum. Our case is a 65-year-old lady who presented with pain in the right upper abdomen associated with nausea and vomiting. Contrast-enhanced computed tomography and MRI of the abdomen were suggestive of calculus in the infundibulum of the gall bladder with compression over the common bile duct and a large stone in the first part of the duodenum. Upper gastrointestinal endoscopy confirmed the findings but could not retrieve the stone. Cholecystectomy with the retrieval of calculus from the infundibulum and duodenum was performed with the closure of the fistulous opening. The patient did well in the post-operative period and is doing well after nine months of follow-up. Chronic calculus cholecystitis can present in varied forms, and one should be aware of such rare complications and their management.

CROHN’S DISEASE COMPLICATED BY ILEOSIGMOID FISTULA: ASSESSMENT AND MANAGEMENT UPDATE

Abstract BACKGROUND The preoperative evaluation of Crohn’s-related ileosigmoid fistula (ISF) is complex with multiple preoperative diagnostic modalities available. Intraoperative management is also complicated when deciding whether to repair the fistula or resect the involved sigmoid. How these choices impact outcomes is not clear. We aim to evaluate the impact of sigmoid resection versus conservative fistula repair on postoperative complications when treating ISF. METHODS Patients with Crohn’s disease (CD) undergoing ileocolic resection in the setting of an ISF between January 1, 2007 and December 31, 2017 were identified. A retrospective chart review was conducted to collect data on preoperative workup, intra-operative technique, and 30-day complications. Intra-abdominal sepsis was defined as the presence of an intra-abdominal abscess or anastomotic leak from the sigmoid colon postoperatively. Univariate comparisons were performed between those undergoing primary repair versus sigmoid resection with primary anastomosis. RESULTS 61 patients (62.3% female) with a median age of 37 years (range, 18-73)were included. Computed tomography enterography (CTE) and magnetic resonance enterography (MRE) each had a sensitivity of 100% versus 42% sensitivity for colonoscopy. When accounting for pre-operative endoscopy results, patients with endoscopic sigmoidal mucosal CD more often underwent sigmoid resection than patients with a normal sigmoidal mucosa or only a solitary fistulous opening in the sigmoid colon (p&amp;lt;0.001). When comparing primary repair vs sigmoid resection there was no difference in the occurrence of intra-abdominal septic complications (p=0.342) or anastomotic leak complication (p=0.239). CONCLUSION In summary, our study shows that conservative repair of the fistula is a safe option. Appropriate patient assessment and preoperative identification of the fistula is critical so that the management strategies for ISF and the potential implications can be discussed with the patient. CTE and MRE are the modalities of choice to diagnose ISF, while colonoscopy has a role in staging the burden of mucosal disease in the sigmoid colon. These tests help guide surgical decision-making with respect to resection versus primary repair of the sigmoid colon and will allow patients in whom the sigmoid colon is an innocent bystander to undergo a less extensive operation.

CROHN’S DISEASE COMPLICATED BY ILEOSIGMOID FISTULA: ASSESSMENT AND MANAGEMENT UPDATE

The preoperative evaluation of Crohn’s-related ileosigmoid fistula (ISF) is complex with multiple preoperative diagnostic modalities available. Intraoperative management is also complicated when deciding whether to repair the fistula or resect the involved sigmoid. How these choices impact outcomes is not clear. We aim to evaluate the impact of sigmoid resection versus conservative fistula repair on postoperative complications when treating ISF. Patients with Crohn’s disease (CD) undergoing ileocolic resection in the setting of an ISF between January 1, 2007 and December 31, 2017 were identified. A retrospective chart review was conducted to collect data on preoperative workup, intra-operative technique, and 30-day complications. Intra-abdominal sepsis was defined as the presence of an intra-abdominal abscess or anastomotic leak from the sigmoid colon postoperatively. Univariate comparisons were performed between those undergoing primary repair versus sigmoid resection with primary anastomosis. 61 patients (62.3% female) with a median age of 37 years (range, 18-73)were included. Computed tomography enterography (CTE) and magnetic resonance enterography (MRE) each had a sensitivity of 100% versus 42% sensitivity for colonoscopy. When accounting for pre-operative endoscopy results, patients with endoscopic sigmoidal mucosal CD more often underwent sigmoid resection than patients with a normal sigmoidal mucosa or only a solitary fistulous opening in the sigmoid colon (p<0.001). When comparing primary repair vs sigmoid resection there was no difference in the occurrence of intra-abdominal septic complications (p=0.342) or anastomotic leak complication (p=0.239). In summary, our study shows that conservative repair of the fistula is a safe option. Appropriate patient assessment and preoperative identification of the fistula is critical so that the management strategies for ISF and the potential implications can be discussed with the patient. CTE and MRE are the modalities of choice to diagnose ISF, while colonoscopy has a role in staging the burden of mucosal disease in the sigmoid colon. These tests help guide surgical decision-making with respect to resection versus primary repair of the sigmoid colon and will allow patients in whom the sigmoid colon is an innocent bystander to undergo a less extensive operation.Table 1Descriptive analysisView Large Image Figure ViewerDownload Hi-res image Download (PPT)

Supra-auricular presentation of a first branchial cleft anomaly

Branchial anomalies are congenital lesions that occur as a result of incomplete obliteration of the branchial apparatus during foetal development. Due to their complex presentations, they are commonly misdiagnosed and pose a challenge in treatment. This report features a girl, aged 1 year and 2 months, with Goldenhar syndrome with right microtia, presenting with a rare supra-auricular fistulous opening to the external auditory canal, with a communicating tract in the neck.

S2335 An Unusual Source of Massive Upper GI Bleed

Introduction: Pseudoaneurysms affecting main abdominal arteries can manifest as massive gastrointestinal (GI) bleed that carries a high mortality. We report a case of massive upper GI bleed due to splenic artery pseudoaneurysm. Case Description/Methods: A 72-year-old female with a history of Roux-en-Y gastric bypass presented to the emergency department with an episode of hematemesis. During initial evaluation, the patient was unresponsive and pulseless. An orogastric tube returned 100 cc of bloody gastric contents. The patient was started on PPI drip, vasopressors, packed red blood cells transfusion and admitted to intensive care unit. The patient continued to pass large, maroon bowel movements. EGD demonstrated a large adherent clot at gastrojejunal (GJ) anastomosis, and two non-bleeding cratered gastric ulcers with no stigmata of bleeding in the gastric pouch. Repeat EGD for worsening anemia despite transfusions showed fresh blood at the GJ anastomosis and two discrete oozing ulcers, each about 1cm in the gastric pouch. Both lesions were treated with endoscopic therapy. However, the patient continued to have melanotic stools. Third EGD demonstrated an adherent clot at GJ anastomosis. Underneath the clot, was a cratered ulcer with a fistulous tract. Endoscope passed into the fistulous opening with ease, but only a blood clot could be visualized and the scope was withdrawn. The patient remained hypotensive and continued to pass melena. Fourth EGD revealed fresh blood in the entire examined stomach and at the anastomosis site. A source of rapid bleeding could not be identified. Emergent angiogram demonstrated a pseudoaneurysm in the midportion of the splenic artery. A coil and glue embolization of the splenic artery was performed. Post angiogram, there was no recurrence of GI bleeding. After a prolonged hospital course, the patient was discharged to a skilled nursing facility. Discussion: A pseudoaneurysm is a communicating sac within the lumen of the artery. In contrast to true aneurysms, which are usually asymptomatic, pseudoaneurysms are nearly always symptomatic and carry a high risk of rupture. A vascular-enteric fistula is usually found either on endoscopic examination or via angiography. Therapy with angiographic embolization of the pseudoaneurysm is almost always indicated due to high risk of recurrence of severe hemorrhage. If access to the splenic artery fails, endoscopic ultrasound guided coil and glue has recently become an accepted treatment method.Figure 1.: A suspected 11 mm jejunal fistula found in the ulcerated GJ site through which the endoscope was passed, but only blood clot could be visualized.

S2384 Recurrent GI Bleeding From Colo Pancreatic Fistula – A Rare Entity

Introduction: Acute pancreatitis is an acute inflammatory condition affecting the pancreas. Colonic complications rarely occur with acute and chronic pancreatitis. Localized ileus, obstruction, colonic ischemia, hemorrhage and fistula formation have been reported together with acute pancreatitis. Colo-pancreatic fistula occurs at a rate of 3% to 10% in patients with severe acute pancreatitis. Here, we discuss the case of a patient with recurrent GI bleeding from a colo-pancreatic fistula. Case Description/Methods: A 62-year-old White male with past medical history of COPD, CAD s/p PCI, history of paroxysmal atrial fibrillation on Eliquis, diabetes presented with complaints of bleeding per rectum. He denied any other complaints. MRI abdomen showed pancreatic pseudocyst with possible fistulization of the pancreatic pseudocyst to the proximal descending colon (Fig 1A). Patient underwent EGD and colonoscopy. Colonoscopy showed evidence of pancreatico enteric fistula distal to the splenic flexure, the remnants were cleared on lavage and patient was discharged once stable (Fig 1B). One month later patient presented with another episode of recurrent GI bleeding he required 2 units of PRBC given the prior findings on the colonoscopy, patient was referred to pancreatic surgeon for further intervention of the colo-pancreatic fistula. Discussion: CPF is a rare condition associated with high mortality in patients with acute pancreatitis. Abdominal CT with or without contrast is often used for diagnosis; however, colonoscopy is also used to detect CPF. Given the anatomical proximity of the left part of the colon to the pancreas, CPF is commonly seen on the left side. Patients present with symptoms such as nausea, abdominal pain, vomiting and gastrointestinal bleeding. In contrast to other pancreatic enteric fistulas, CPF is associated with a high risk of severe hemorrhage, perforation or infection. Unlike other pancreatic enteric fistulas CPF do not close spontaneously, surgery is often the recommended treatment; however, less invasive endoscopic interventions, such as those using conventional hemoclips or over the scope clip, have been reported to have successful outcomes.Figure 1.: Fig 1A: MRI Abdomen showing pancreatic pseudocyst (shown by two blue arrows). Fig 1B: Colonoscopy showing fistulous opening in the descending colon distal to splenic flexure (shown by black arrow).