Fistula Closure Rate Research Articles

Analysis of a Surgical Treatment for Persistent Urorectal Fistulas after Radical Cancer Surgery: A Comparison of Prostate Cancer and Rectal Cancer

Introduction: The study aimed to present our experience of surgical treatment for urorectal fistulas (URF) that develop after cancer surgery. Materials and Methods: Fourteen patients with URF who were treated at our institution from 2005 through 2015 were retrospectively analyzed. Among these, 7 patients had previous surgical treatment of prostate cancer (PC) and the other 7 had been treated for rectal cancer (RC). The fistula was resected through a perineal incision, and the urinary and fecal defects were separately closed with the hinge flap method followed by interposition of a muscle flap transfer. Results: The overall fistula closure rate was 79%. Although the closure rate of the URF was lower in patients with previous RC surgery compared to the PC patients (57 vs. 100%), it did not reach statistical significance. Conclusions: URF treatment using an interposition muscle flap offers a high success rate of fistula closure. However, complicated fistulas occurring after RC surgery involving the prostate or the seminal vesicle might be difficult to repair by this surgery alone.

P672 Surgical and anti-TNFs combined therapy prevents Crohn's perianal fistula recurrence: a systematic review and meta-analysis

Background: The management of perianal Crohn's disease (CD) fistula represents a significant challenge. We aimed to conduct a meta-analysis to evaluating the efficacy and safety of combined surgical and anti-TNFs treatment compared with either single therapy in fistulising perianal CD. Methods: MEDLINE, EMBASE and the Cochrane database were searched. The primary outcome was the number of patients who developed fistula closure as defined by the primary studies. Results: Eight studies (3 prospective studies and 5 retrospective studies) invoving 688 patients were included. The rate of fistula closure of the combination therapy (78.5%, 197/251) was not significant higher compared with the surgical therapy alone (65.2%, 215/330) (OR 2.21, 95% CI 0.83–5.90, p=0.11). Similarly, neither the rate of complete closure nor the rate of partial closure was significantly different between the two groups. Significant lower proportion of patients in the combination group developed fistula recurrence (20.8%, 11/53) compared with the single surgical group (76.1%, 35/46) (OR 0.13, 95% CI 0.03–0.58; p=0.007). No significant difference observed between the combination therapy and anti-TNF therapy alone in the rate of fistula closure. However, the combination therapy was associated with a 76% risk reduction of fistula recurrence (OR 0.24, 95% CI 0.06–0.93, p=0.04, n=57). The adverse events were mostly related to anti-TNFs infusion. Conclusions: Combined surgical and anti-TNFs therapy did not significant improve the fistula closure than the surgery or anti-TNFs therapy alone. However, it is superior to either therapy in preventing fistula recurrence of fistulising perianal CD without causing more adverse events.

Local application of adipose-derived mesenchymal stem cells supports the healing of fistula: prospective randomised study on rat model of fistulising Crohn’s disease

Objective: Local application of adipose-derived mesenchymal stem cells (ADSC) represents a novel approach for the management of perianal fistula in patients with Crohn’s disease. A randomised study on an animal model was performed to investigate the efficacy and to detect the distribution of implanted ADSCs by bioluminescence (BLI).Materials and methods: A caecostomy was used as a fistula model in 32 Lewis rats. The ADSCs were isolated from transgenic donor expressing firefly luciferase. Animals were randomly assigned to groups given injections of 4 × 106 cells (n = 16, group A) or placebo (n = 16, group B) in the perifistular tissue. Fistula drainage assessment was used to evaluate the fistula healing. After application of D-luciferin, cell viability and distribution was detected using an IVIS Lumina XR camera on days 0, 2, 7, 14 and 30.Results: The fistula was identified as healed in 6 (38%) animals in group A vs. 1 case (6.3%) in group B (p = .033). The BLI was strongest immediately after administration of ADSCs 31.2 × 104 (6.09–111 × 104) p/s/cm2/sr. The fastest decrease was observed within the first 2 days when values fell by 50.2%. The BLI 30 days after injection was significantly higher in animals with healed fistulas – 8.23 × 104 (1.18–16.9 × 104) vs. 1.74 × 104 (0.156–6.88 × 104); p = .0393.Conclusions: Local application of ADSCs resulted in significantly higher fistula closure rate on an animal model. BLI monitoring was proved to be feasible and showed rapid reduction of the ADSC mass after application. More viable cells were detected in animals with healed fistula at the end of the follow-up.

Reconstructive Surgery for Bronchopleural Fistula and Empyema: New Application of Free Fascial Patch Graft Combined with Free Flap

Background:Postoperative bronchopleural fistula (BPF) and empyema are not uncommon after lung cancer surgery. Some patients require reconstructive surgery to achieve wound healing. In this report, we describe a novel method of reconstructive surgery for BPF and empyema.Methods:From 1996 through 2014, we performed reconstructive surgery for the treatment of BPF and empyema in 13 cases. BPF or a pulmonary fistula was present in 11 patients at the time of reconstruction. Of these, a free fascial patch graft combined with a free soft tissue flap was used to close the fistula in 6 cases. In the other 5 cases, primary fistula closure or direct coverage of the fistula with a transferred flap was performed. Medical records were retrospectively reviewed, and postoperative results were compared for these methods.Results:All the flaps were transferred successfully except in 1 case. Although postoperative air leakage was observed in 5 cases, most of these healed with conservative management. Of 11 fistulas, 8 were successfully controlled. Although differences were not statistically significant, a higher success rate of fistula closure was obtained in patients with a fascial patch graft (100% vs 40%). As a result, 9 patients could be discharged from the hospital, but 4 died during their hospital stay.Conclusion:Although the incidence of in-hospital mortality was high, fistula closure with a fascial patch graft combined with free flap transfer was effective for the treatment of BPF and empyema, compared with other procedures.

Editorial Comment

Rectourethral fistula (RUF) is perhaps the most feared complication following treatment for prostate or colorectal cancer. It has a significant impact on quality of life, usually requires a prolonged course of management, and may result in an unanticipated change in long-term treatment outcome. The authors have long been proponents of the perineal approach for repair of postsurgical and post-ablative RUFs, and have demonstrated a high rate of fistula closure with very acceptable short- and long-term complications with this approach. We have also primarily used this technique since 2004 with similar findings. It is a very well-tolerated procedure, which is important as many of the patients with post-ablative RUF are older with medical comorbidities. In addition, the perineal approach allows surgical access for concomitant urethral reconstruction and gracilis flap interposition as pointed out by the authors.

A systematic literature review on the use of vacuum assisted closure for enterocutaneous fistula.

Enterocutaneous fistula (ECF) is considered to be one of the most challenging complications a general surgeon can encounter. The current mainstay of treatment is surgical closure, associated with significant morbidity and mortality. Vacuum assisted closure (VAC) has been successfully used for closure of persistent abdominal wounds for a number of years. This study aims to investigate whether current literature supports the use of VAC for ECF. A PubMed search of the search terms 'enterocutaneous fistula' and 'vacuum assisted closure/therapy' was performed in December 2014. Results were restricted to articles involving human subjects with an available abstract and full text written between 1950 and 2014. The end-points analysed included rate of fistula closure, duration of follow-up, and morbidity and mortality where available. Ten studies (all level IV) including 151 patients were examined. In all except one, surgery was the underlying aetiology with median number of fistulae per patient of one. The median rate of closure with VAC was 64.6% (7.7-100%) with healing occurring within 58 (12-90)days. Follow-up was only mentioned in three of the 10 studies, in which the patients were followed for 3, 20 and 28.5months. No complications were reported in all but one of the studies, in which abdominal wall disruption and intestinal obstruction were identified in a minority of patients. The included studies suggest that VAC therapy may be considered a safe treatment for ECF. The current evidence is generally of low level and characterized by heterogeneity. Definitive recommendations based on this information cannot therefore be made. Further studies are necessary to establish any proven benefit over standard surgical or conservative therapy.

Similar outcomes for anti-tumor necrosis factor-α antibody and immunosuppressant following seton drainage in patients with Crohn's disease-related anal fistula.

Anal fistula is common in patients with Crohn's disease (CD) and leads to significant morbidity. The efficacy of seton drainage combined with anti-tumor necrosis factor-α monoclonal antibody (anti-TNF-α) or immunosuppressant in the treatment of CD-related anal fistula remains unclear. The aim of the present study was to compare the efficacy between seton drainage combined with anti-TNF-α and seton drainage combined with immunosuppressant postoperatively on the treatment of CD-related anal fistula. A total of 65 patients with CD-related anal fistula who had received seton drainage combined with postoperative medication were divided into an antibiotics only group, anti-TNF-α group and immunosuppressant group; all patients were treated with antibiotics. Fistula closure, external orifice exudation rate and recurrence rate were assessed among these patients. The duration of follow-up ranged from 3 to 84 months with an average of 25.3 months. There were 11 (16.9%) cases of recurrence after seton drainage, 9 of which underwent a second seton drainage. In the total study group, 34 (52.3%) cases achieved complete fistula closure, and 10 (15.4%) cases showed external orifice exudation. No significant difference was found among these three groups, regarding fistula closure rate, closure time of fistula and recurrence rate. The external orifice exudation rate was significantly higher in the anti-TNF-α group compared with the antibiotics only group and immunosuppressant group (P=0.004 and P=0.026, respectively). Seton drainage is an effective treatment for CD-related anal fistula. The efficacy is similar whether combined with anti-TNF-α or immunosuppressant.

Enterocutaneous fistula: analysis of clinical outcomes from a single Victorian tertiary referral centre

Enterocutaneous fistulas (ECFs) are complex and can result in significant morbidity and mortality. The study aimed to evaluate ECF outcomes in a single tertiary hospital. A retrospective study of all patients treated with ECF between the period of January 2009 and June 2014 was conducted. Baseline demographic data assessed included the primary aetiology of the fistula, site of the fistula and output of the fistula. Outcomes measures assessed included re-fistulation rate, return to theatre, wound complications, fistula closure rate and death over the study period. A total of 16 patients with ECF were recorded within the study period. Mean age of the patient cohort was 55.8 ± 11.8 years with a female predominance (11 females, 5 males). Primary aetiology were Crohn's disease (31%), post intra-abdominal surgery not related to bowel neoplasia (50%) and post intra-abdominal surgery related to bowel neoplasia (19%). Majority of the fistulas developed from the small bowel (75%) and had low output (63%). Operative intervention was required in 81% of patients with an overall closure rate of 100%. Median operations required for successful closure was 1.15 operations. Mean duration between index operation and curative operation was 8 ± 12.7 months. Appropriate bundle of care (perioperative care, surgical timing and surgical technique) can produce excellent results in patients with ECF.

Use of a purified collagen membrane to aid closure of palatal fistulae

Fistula formation following closure of palatal clefts remains a difficult clinical complication. A significant recurrence rate has also been reported following attempted closure. We present our results of fistula closure augmented with Bio-Gide(®), a purified porcine collagen membrane designed to promote guided tissue regeneration. We reviewed the records of 263 patients operated between 1993 and 2011 for closure of palatal fistula. The patients selected comprised 61 who underwent fistula closure augmented with Bio-Gide and 202 with other techniques in the absence of Bio-Gide. We reviewed the age at surgery, sex, location of fistula, cleft type and outcome. Operation success was defined as an asymptomatic patient along with visible confirmation of closure of the fistula. The overall fistula closure rate was 75% in the Bio-Gide group and 63% in the non-Bio-Gide group (p=0.070) and 86% versus 61% in the unilateral cleft palate patients (p=0.027). Bio-Gide has improved the success rate in fistula closure in this study. Using this technique, fistula closure can be performed as a day case procedure and does not need to transgress any original suture lines; an additional advantage is that this procedure does not require harvesting of any autologous tissue to augment the repair.

Study of outcome of patient with faecal fistula

Background: Approximately 80% gastrointestinal fistulas occur following surgery. Due to the high morbidity and mortality associated with gastrointestinal fistula, effective treatment is important. Therefore, this study was conducted to study the outcome of management of patients of gastrointestinal fistula. Methods: 30 Patients developing the condition following surgery were included. All patients were treated either conservatively or operatively by various means and varying period of time. Treatment was focused on the correction of dehydration, controlling sepsis, management of electrolyte imbalance. Results: Younger patients had better fistula healing rate (85%) than older (70%). A high rate of spontaneous healing was observed (85%) in patients who were managed conservatively. Patients with low output fistula had better fistula closure rate as compared to high output fistula. Ileum was the most common site for fistula formation, account for 43.33% of all fistulas. Spontaneous healing rate was better in fistula involving large bowel and duodenal fistula. Patients having both anemia and hypoproteinemia had poor healing rate (72.73%) as compared to those having only anemia and hypoproteinemia. Conclusions: Conservative management with emphasis on improvement of nutrition, control of sepsis, management of fluid and electrolyte balance and control of fistula output supersedes than operative management. Operative intervention must be done in selected cases after improvement of nutritional status and control of infection.

Obstetric fistula management and predictors of successful closure among women attending a public tertiary hospital in Rwanda: a retrospective review of records.

BackgroundGlobally, 50,000–100,000 women develop obstetric fistula annually. At least 33,000 of these women live in Sub-Saharan Africa where limitations in quality obstetric care and fistula corrective repairs are prevalent. Among women with fistula seeking care at public health facilities in resource-limited settings, there is paucity of data on quality of care received. The aim of this study was to characterize obstetric fistula among Rwandan women managed at a public tertiary hospital and evaluate for predictors of successful fistula closures.MethodsA retrospective review of records for all obstetric fistula women managed at a public referral health facility between 2007 and 2013 was performed. Patient socio-demographics, obstetric characteristics and fistula repair outcomes data were reviewed. A multivariate logistic regression model was used to analyse for predictors of successful fistula repair outcomes.ResultsA total of 272 women aged between 16 to 78 years and with a mean age of 34.6 years were included. Of these, 93 (34.2 %), 48 (17.6 %), 65 (24 %) and 64 (23 %) women had vesico-vaginal fistula, recto-vaginal fistula, urethro-vaginal fistula and vesico-uteral fistula types, respectively. Successful fistula closure was achieved among 86.3 %. Women with fistula who reported being in labour for ≥3 days, having ≥1 previous fistula repair attempt, and having lived with the fistula for >1 year, had significantly lower odds of successful repair outcomes.ConclusionsAmong 272 women with obstetric fistula managed in this study, 69.5 and 26.5 % of their fistula were causally associated with obstructed labour complications and iatrogenic factors, respectively. Successful fistula closure rates of about 89 % among women of index repair attempt were achieved. Conversely, reported histories of ≥3 days in labour, ≥1 previous failed attempts at repair and a fistula duration of >1 year, were significant determinants of failed fistula closures. To effectively mitigate obstetric fistula burden in Rwanda, a comprehensive package of services including quality emergency obstetric care, increased availability of and access to quality fistula repair, active surveillance to identify community-based women with fistula and a strong political will towards effective fistula care, are recommended.

Eosphago-Gastro-Duodenal Stenting for Gastric Leaks Could Be More Effective Than Esophagogastric Stenting After Laparoscopic Sleeve Gastrectomy

Sleeve gastrectomy is commonly used procedure for the surgical management of morbid obesity. It is safe and effective procedure but limited by a rate of gastric leak almost 5.3%. We present a case of gastric leak with fistula successfully managed by fully covered esophageal metallic stents placed in telescoping fashion between the distal esophagus and duodenal bulb bypassing the entire stomach.Figure 1Figure 261 year old female with history of morbid obesity underwent sleeve gastrectomy at outside facility. During the procedure a tear was identified which was stapled and no leak was identified after evaluation upper GI study (UGI) post operatively. On postoperative day 2, patient presented to ER with fever and abdominal pain. She underwent CT abdomen which revealed complex fluid collection anterior to stomach with a communicating fluid collection concerning for a gastric leak (GL) with possible 2 gastric fistula (GF). Patient was admitted to MICU because of sepsis and started on antibiotics. GI team was consulted for endoscopic management of GL with fistula. Patient underwent EGD, which showed 2 fistula orifices draining copious amount of debris. The 1st larger one was located at 40cm from incisor and the 2nd was at 38 cm, 0.5 cm below Z line. The larger fistula was closed by over the scope clip. A self-expandable fully covered esophageal metallic stent (FCEMS) 23 X 155 was placed across the fistulas to seal them off. No drainage was noted after the stent placement. UGI 48 hours later revealed a high-grade stricture at the distal end of stent and contrast seeping around the stent with leakage through the proximal GF. Patient underwent repeat EGD under fluoroscopy; stent was partially migrated into the stomach and touching mucosa causing stent obstruction. Therefore, stent was repositioned and another FCEMS was placed in a telescoping fashion bypassing the entire gastric sleeve and distal end of the stent was beyond the pylorus but within the duodenal bulb. Patient was kept NPO and had repeat UGI in 4 weeks time, which revealed contrast passing through the stents with out any leak. Patient underwent EGD, which showed stents are in place in a telescoping fashion bypassing the gastric sleeve. The stents were successfully removed. Repeat UGI after stent removal was negative for gastric leak. Patient was started on oral diet and tolerated it well. Bypassing the entire stomach by endoscopically placing esophago-gastric-duodenal stent is likely to have better success rate of gastric fistula closure then esophago-gastric stents.

Use of Octreotide for the Management of Chyle Fistula Following Neck Dissection.

Chyle fistula is an uncommon complication of neck surgery. A variety of management strategies have been described, including diet restriction, parenteral nutrition, use of pressure dressings, and revision surgery. Octreotide has been used with success in patients with neck and thoracic chyle fistulas, but data regarding efficacy in neck chyle fistulas are lacking. To evaluate the efficacy of octreotide for use in patients with postoperative chyle fistulas. Retrospective review of 12 patients who received octreotide for neck chylous fistula after neck dissection was performed during the period 2004 through 2014 at 2 tertiary care academic hospitals. Patients with postoperative neck chyle fistulas were given a restricted diet and subcutaneous octreotide. The main outcome was fistula closure rate, defined as fistula resolution without surgical intervention. Secondary outcomes of fistula duration (days from detection until resolution), length of hospital stay (surgery to discharge), and treatment complications were also examined. All 12 patients had resolution of their neck chyle fistula with octreotide therapy without need for revision surgery. Mean (SD) hospital stay was 8.7 (4.76) days, with a range of 3 to 18 days. The chyle fistula resolved after a mean (range) 5.5 (2-11) days. Self-resolving nausea was encountered in 1 patient from octreotide use, and 1 patient developed a salivary fistula as a result of the chylous fistula. In these patients, octreotide was safe and effective in resolving neck chylous fistulas. Octreotide therapy appears superior to traditional conservative measures of diet restriction and pressure dressings when compared with literature rates. A prospective study is needed to confirm results, but octreotide therapy should be considered as first-line conservative management for neck chyle fistulas that occur after neck surgery.

Evaluation and Management of Rectourethral Fistulas After Prostate Cancer Treatment

Most men newly diagnosed with prostate cancer will undergo local treatment with prostatectomy, radiation, or tissue ablation. A small percentage of these men will develop a rectourethral fistula, a complicated disease that requires a multidisciplinary approach to management. Diagnosis is typically made with a careful history and physical exam with endoscopy and select imaging recommended in all patients. Fistulas resulting from prostatectomy, radiation, or tissue ablative technology are approached differently due to local tissue changes following therapy. Post-radiation and thermal ablation fistulas have a lower fistula closure rate due to the deleterious effect of the primary treatment on local tissue. It is imperative that the patient understands the complexity of treatment and sets reasonable goals for treatment.

The results of seton drainage combined with anti-TNFα therapy for anal fistula in Crohn's disease.

Combined infliximab and sphincter-sparing surgery can be effective in perianal fistula associated with Crohn's disease (CD). This study aimed to assess the efficacy of local surgery combined with infliximab on sustained fistula closure and to identify predictive factors for response after this combined treatment. Between 2000 and 2010, 81 patients with fistulising perianal CD were included in this observational study. Drainage with a loose seton was followed by infliximab therapy. The primary end-points were the rate of complete fistula closure and time required for this to occur. The fistula was complex in 71 (88%) of the 81 patients. Local proctological surgery was carried out in 77 (95%), including seton drainage in 62 (80.5%) of these. This was continued for a median duration of 3.8months and the patient then received infliximab therapy. The median follow-up after treatment was 64months (2-263). Initial complete closure of the fistula occurred in 71 (88%) cases at a median interval of 12.4months (1-147) from the start of treatment. Recurrence was observed in 29 (41%) patients at a median interval of 38.5months (2-48) from the start of treatment. They were treated again with combined treatment with successful closure in 19 (65.5%) patients. The total rate of closure of the fistula was 75.3%. Female gender, anal stenosis, rectovaginal and complex fistula formation were factors independently associated with failure of combined treatment. Seton drainage for several months combined with infliximab therapy is effective in closing the fistula in 75% of patients with complex perianal fistula formation associated with CD.

Good clinical outcomes from a 7-year holistic programme of fistula repair in Guinea.

Female genital fistula remains a public health concern in developing countries. From January 2007 to September 2013, the Fistula Care project, managed by EngenderHealth in partnership with the Ministry of Health and supported by USAID, integrated fistula repair services in the maternity wards of general hospitals in Guinea. The objective of this article was to present and discuss the clinical outcomes of 7years of work involving 2116 women repaired in three hospitals across the country. This was a retrospective cohort study using data abstracted from medical records for fistula repairs conducted from 2007 to 2013. The study data were reviewed during the period April to August 2014. The majority of the 2116 women who underwent surgical repair had vesicovaginal fistula (n=2045, 97%) and 3% had rectovaginal fistula or a combination of both. Overall 1748 (83%) had a closed fistula and were continent of urine immediately after surgery. At discharge, 1795 women (85%) had a closed fistula and 1680 (79%) were dry, meaning they no longer leaked urine and/or faeces. One hundred and fifteen (5%) remained with residual incontinence despite fistula closure. Follow-up at 3months was completed by 1663 (79%) women of whom 1405 (84.5%) had their fistula closed and 80% were continent. Twenty-one per cent were lost to follow-up. Routine programmatic repair for obstetric fistula in low resources settings can yield good outcomes. However, more efforts are needed to address loss to follow-up, sustain the results and prevent the occurrence and/or recurrence of fistula.

Management of pancreatico-pleural fistula: 5 years of experience

Background: Pancreatico-pleural fistula is a rare entity with an incidence of 0.4% seen both in patients with acute and chronic pancreatitis or may follow traumatic and surgical disruption of the pancreatic duct. It presents as massive pleural fluid accumulation and has a high tendency to recur following treatment. Conservative management like inhibition of pancreatic secretion with octreotide and pancreatic duct stenting may help fistula closure in about 31 to 45% of cases. Surgical correction has high mortality up to 10% and but has increased fistula closure rate of 80-90%. Here we present our experience with pancreatico-pleural fistula. Methods: Data of patients admitted with pancreatico-pleural fistula from 2010-2015 in our department were retrospectively analysed. Ten patients were included in this analysis. The average age of presentation was 28.3 years. Results : There were 8 male and 2 female patients. Alcoholic pancreatitis - most common cause with chronic pancreatitis (80% n = 8), idiopathic pancreatitis (20% n=2). Mean hospital stay was 18 days; intercostal drainage and inj. octreotide were done in all patients; ERCP (n=5; In 4 patients successful PD stenting was done and in 1 patient could not be done; four patients required pigtail drainage for peripancreatic collection. Recurrence (20% n = 2); Surgery in 3; Mortality – nil. Conclusions: Pancreatico-pleural presents with significant morbidity but can be managed effectively with medical therapy and ERCP stenting in most of the patients. Surgery may be required for failed conservative therapy or for recurrences.

Immediate technical and delayed clinical outcome of fistula closure using an over-the-scope clip device.

An over-the-scope clip (OTSC) device was designed for closure of acute perforations, fistulas, leaks, and non-variceal gastrointestinal bleeding. Previous data show a high rate of early fistula closure using the OTSC; however, data on long-term fistula closure are scant. We report our experience using an OTSC for closure of chronic gastrointestinal fistulas. Retrospective review of all patients, who underwent OTSC placement at Mayo Clinic Rochester and Virginia Mason Medical Center for closure of chronic fistulas from October 2011 to September 2012, was performed. Initial technical success was defined by lack of contrast extravasation immediately after OTSC placement. Delayed success was defined by resolution of the fistula without the need for additional therapies. Recurrent fistula was defined by the recurrence of symptoms and/or re-demonstration of fistula after initial success. Forty-seven unique patients (24 men; mean age 57 ± 14 years) underwent 60 procedures using the OTSC for closure of gastrointestinal fistulas. Fistula locations were: small bowel (n = 18), stomach (n = 16), colo-rectum (n = 10), and esophagus (n = 3). Fistulas related to previous percutaneous endoscopic gastrostomy/jejunostomy (n = 10) or prior bariatric procedure (n = 10) were the most common etiologies. Initial technical success occurred in 42/47 (89%) index cases; however, 19/41 (46%) patients developed fistula recurrence at a median of 39 days (IQR 26-86 days). The retained OTSC was present adjacent to the fistula in 16/19 (84%) at repeat intervention. Patients were followed for a median length of 178 days (IQR 63-326 days), and only 25/47 (53%) patients demonstrated delayed clinical success using OTSC. Initial technical fistula closure can be achieved using OTSCs. Recurrent fistulas at the same location occur in approximately 50% of cases despite frequent OTSC clip retention.

Surgical management of complex rectourethral fistulas in irradiated and nonirradiated patients.

Rectourethral fistulas are an uncommon, yet devastating occurrence after treatment for prostate cancer or trauma, and their surgical management has historically been nonstandardized. Anecdotally, irradiated rectourethral fistulas portend a worse prognosis. To review outcomes after surgical treatment of rectourethral fistulas in radiated and nonirradiated patients to construct a logical surgical algorithm. A retrospective review was undertaken of all patients presenting to Duke University with the diagnosis of rectourethral fistula from 1996 to 2012. Thirty-seven patients presented with and were treated for rectourethral fistulas: 21 received radiation, and a rectourethral fistula from trauma or iatrogenic injury developed in 16. The groups were compared regarding their functional outcomes, including healing, time to healing, continence, and recurrence. There were no significant differences in patient characteristics between groups. Patients who had irradiated rectourethral fistulas had a significantly higher rate of passage of urine through the rectum and wound infections, a higher rate of crystalloid infusion and blood transfusion requirements, and a longer time to ostomy reversal than nonirradiated patients. Patients who had irradiated rectourethral fistulas underwent more complex operative repairs, including gracilis interposition flaps (38%) and pelvic exenterations (19%), whereas nonirradiated patients most commonly underwent a York-Mason repair (50%). There were no statistically significant differences in rectourethral fistula healing or in postoperative and functional outcomes. Only 55% of irradiated patients had their ostomy reversed versus 91% in the nonirradiated group. This study was limited by the small sample size and the retrospective nature of the review. Repair of rectourethral fistulas caused by radiation has a significantly higher wound infection rate and median time to healing, and lower overall stomal reversal rate than nonradiation-induced rectourethral fistulas. Patients who had irradiated rectourethral fistulas required significantly more complex operations, likely contributing to the higher morbidity, mortality, and lower fistula closure rate. We propose an algorithm for approaching rectourethral fistulas based on etiology.

Efficacy of tumor necrosis factor-alpha inhibitors in fistulising perianal Crohn’s disease

Tumor necrosis factor-alpha inhibitors are increasingly used in the treatment of severe Crohn's disease. The aim of the authors was to assess retrospectively the short and long term efficacy of tumor necrosis factor-alpha inhibitors in fistulising Crohn's disease. Responses to therapy was determined using Crohn's Disease Activity Index, Perianal Disease Activity Index, the rate of complete fistula closure and the additional surgical procedures during biological therapy. After 12 weeks the perianal activity was decreased in more than 80% of the cases, and the complete remission rate was about 60%. After one year of therapy about one third of the patients had fistula closure, but after cessation of the biological therapy recurrence of fistulas was detected in every second patient. In most cases additional immunosuppressive therapy was necessary during biological treatment. During the one-year therapy period additional surgical treatments were performed in 45% of patients; seton insertion and abscess drainage were the most frequent procedures. Tumor necrosis factor-alpha inhibitor therapy is effective in the treatment of perianal Crohn's disease, however, additional immunosuppressive drugs and rectum sparing surgical procedures were necessary during the one-year treatment period. Because of the high rate of fistula recurrence, long term tumor necrosis factor-alpha treatment may be useful.