Sigmoid Fistula Research Articles

Minimally invasive versus open ileal ureter with ileocystoplasty: comparative outcomes and 5-year experience

PurposeTo present the experience of ileal ureter with ileocystoplasty (IUC), and compare the outcomes of IUC in minimally invasive procedures to open procedures.Patients and methodsFrom December 2017 to April 2023, twenty patients underwent IUC in open or minimally invasive (including laparoscopic and robotic) procedures. The baseline characteristics, perioperative data and follow-up outcomes were collected. Success was defined as relief of clinical symptoms, stable postoperative serum creatine and absence of radiographic obstruction. The perioperative and follow-up outcomes of open procedures and minimally invasive procedures were compared.ResultsThe etiology included pelvic irradiation (14/20), urinary tuberculosis (3/20) and surgical injury (3/20). Bilateral ureter strictures were repaired in 15 cases. The surgeries conducted consisted of open procedures in 9 patients and minimally invasive procedures in 11 patients. Compared to open procedures, minimally invasive surgeries had less median estimated blood loss (EBL) (100 ml vs. 300 min, p = 0.010) and shorter postoperative hospitalization (27 d vs. 13 d, p = 0.004). Two patients in the open group experienced grade 3 complications (sigmoid fistula and acute cholecystitis in one patient, and pulmonary embolism in another patient). Over a median follow-up period of 20.1 months, the median bladder functional capacity was 300 ml, with a 100% success rate of IUC.ConclusionIUC is feasible in both open and minimally invasive procedures, with acceptable complications and a high success rate. Minimally invasive procedures can have less EBL and shorter postoperative hospitalization than open procedure. However, prospective studies with larger groups and longer follow-up are needed.

Ileal Artery to Sigmoid Fistula Following Cystectomy and Radiation: A Case Report

Abstract Arterial-enteric fistulas are a rare but devastating complication that can occur as a result of surgery or radiation exposure. Although this condition is most frequently seen following manipulation of the vasculature, especially in the presence of the vascular graft, other causes have been reported. Twenty-five cases have been reported in the literature, mostly related to previous vascular grafts. We present a case of ileal artery to sigmoid colon fistulas caused by previous resection of bladder cancer and radiation.

Робот-ассистированная радикальная цистэктомия с ортотопической деривацией мочи

Introduction Robot-assisted radical cystectomy (RARC) with intracorporeal neobladder formation is a complex surgical procedure. Aim To describe the main stages of RARC and to analyze its short-term results. Materials and methods RARC with ileocystoplasty was performed in 16 patients, most of whom were men (n=14). In 15 patients, the indication for surgery was bladder cancer (BCa), while one patient has radiation-induced sigmoid fistula with a formation of small, contracted bladder. During radical cystectomy (RC), the lower ureters were dissected, followed by posterior dissection of the bladder with mobilization from both sides to the pelvic fascia, clipping and transection of the vesical pedicles, and suturing of the dorsal venous complex with urethral dissection. After pelvic lymph node dissection, 40 cm of the ileum was resected, after that two distal segments of 15 cm were U-shaped, and a 1.5 cm incision was made in the lower part of the bowel, followed by a formation of the urethral anastomosis. Then bowel segments were detubularized, and continuous suture on the posterior and anterior walls of the neobladder was done. Ureters were implanted in the proximal tubular part of the resected colon according to the Nesbit technique. Results The mean operation time was 380 minutes. The blood loss ranged from 80 to 200 ml; however, blood transfusion was not performed. Complications during 30-days after RARC were observed in 7 (43.7%) patients, including 4 (25%) of class I-II according to Clavien - Dindo, and 3 (18.7%) of class III-IV. In patients with leakage at the uretero- intestinal anastomosis (n=2) and urethro-neobladder anastomosis (n=1), percutaneous drainage was performed, which allowed to resolve these complications. There were no cases of bowel obstruction. One patient with gastrointestinal bleeding required blood transfusion. The 90-day late complications occurred in 6 (37.5%) patients, including 2 cases of upper urinary tract infection. One patient died of acute myocardial infarction. Conclusion RARC is a contemporary minimally invasive method for muscle-invasive BCa. Stepwise approach to RARC with intracorporeal neobladder formation may reduce the operation time and the rate of complications.

Decidualization of an ovarian endometrioma complicated by a sigmoid fistula during pregnancy: a case report

BackgroundDuring pregnancy, the discovery of adnexal masses remains frequent. Such masses are mostly benign. Ovarian endometrioma is a rare etiology. The diagnosis may be difficult in some situations, such as decidualization. It may be asymptomatic or result in complications for which magnetic resonance imaging is needed.Case presentationWe describe an unusual case of decidualization of an ovarian endometrioma complicated by a sigmoid fistula during a 7-week, 1-day pregnancy in a Arabic patient aged 38 years who developed acute pelvic pain with fever. She had a medical history of unexplored secondary dysmenorrhea. The diagnosis was suspected on the basis of magnetic resonance imaging findings. The management was based on surgery, during which exploration revealed a mass at the expense of the left ovary being very adherent and fistulized to the sigmoid. We performed adnexectomy followed by digestive ostomy. The result of pathological study with immunohistochemistry led to a diagnosis of decidualization of an ovarian endometrioma altered by infection.ConclusionDecidualization of an ovarian endometrioma can lead sometimes to unexpected complications. The decision to provide surgery must be made with caution without delaying treatment in the event of a deep suspicion of malignancy and/or complication. The particular and exceptional complication discovered in our patient is the fistulization to the sigmoid.

S2783 Ileocolonic Fistula Due to Diffuse Large B-Cell Lymphoma: Unusual Presentation of a Rare Disease

INTRODUCTION: Malignant fistula is a rare complication of primary gastrointestinal lymphomas (PGIL) such as primary aggressive diffuse B cell lymphoma (DLBCL) of the ileum. These fistulas are frequently misdiagnosed. Currently there is no standardized treatment approach. We present a case of DLBCL complicated with a malignant ileocolonic fistula in a 55-year-old male with favorable outcome after surgery and chemotherapy. CASE DESCRIPTION/METHODS: A 55-year-old male presented with 3 months of watery non-bloody diarrhea and 3 weeks of abdominal pain associated with nausea. He denied any vomiting, anorexia, weight loss, fever or chills. Labs revealed a CRP of 15.3 mg/dl and leukocytosis of 14.3 k/ul. Non-contrast CT of abdomen and pelvis showed a focal aneurysmal dilation of a small bowel loop in the mid lower abdomen with associated lymphadenopathy and fluid filled sigmoid colon consistent with a small bowel tumor with an enterocolonic fistula (Image). This was confirmed on colonoscopy which showed a large sigmoid fistula 30 cm from the anal verge communicating with the midgut lumen through a medium sized ulcerated mass (image). He underwent en bloc excision. Both colonoscopy and surgical pathology confirmed high grade primary DLBCL, germinal center like originating from the ileum. Post-operative PET/CT scan showed persistent neoplastic process in the left para aortic lymph nodes. He received 6 cycles of R-COEP with complete resolution of symptoms. Follow up PET/CT scan showed no residual disease and was declared to be in complete remission. DISCUSSION: Ileocolonic fistulas due to PGIL is a rare occurrence with only less than 10 cases reports that we were able to find in literature. These fistulas are commonly misdiagnosed due to unspecific clinical presentation. Currently, there is no consensus on the standard treatment approach. We acknowledge the approach of en bloc surgical resection with adjuvant chemotherapy because of the excellent clinical outcomes observed with our patient, but admit that more data is required to demonstrate the most effective approach to treat PGIL.Figure 1.: Unenhanced cross section CT scan of the abdomen showing an ileocolonic fistula with aneurysmal dilation of the small bowel.Figure 2.: Endoscopic picture showing the fistula at 20cm from the anal verge(left) and a small bowel fistulizing mass(right).Figure 3.: H&E (left) and BCL6 (right) stained histology slides showing Malignant high grade DLBCL cells infiltrating the small bowel.

A Mature Cyst Teratoma with Malignant Transformation in Squamous Cell Carcinoma Presenting Like a Sigmoid Fistula: A Case Report of a Rare Differential Diagnosis of a Giant Colonic Diverticulum

Mature cystic teratoma is the most common form of ovarian germ cell tumor. Mature cystic teratoma is a benign tumor, mainly diagnosed in young women, with non-specific symptoms. However, the risk of malignant transformation exists (1-2%). Squamous cell carcinoma is the most frequently encountered histological form. Giant colonic diverticulum is a rare complication of diverticular disease, characterized by a diverticulum larger than 4 cm which can sometimes be confused with other digestive pathologies (appendicitis, small bowel perforation ...). We report a case of an ovarian squamous cell carcinoma arising from a mature cystic teratoma, presenting like a sigmoid fistula, with an initial doubt with the diagnosis of a giant colonic diverticulum. A 68-year-old woman was admitted for chronic hypogastric abdominal pain with a doubt concerning the diagnosis between a mature cystic teratoma and a giant colonic diverticulum. A computed tomography scan was performed revealing a perisigmoid cyst with hydro-aeric level in favor of a giant colonic diverticulum. The pelvic MRI rather suggested a left ovarian cyst, fistulated in the sigmoid colon. Finally, the colonoscopy confirmed this hypothesis with the visualization of a sigmoid fistula located 15cm from the anal margin in connection with a cavity containing hairs. Biopsies revealed a squamous cell carcinoma. After a negative extension assessment, a posterior pelvectomy was performed with pelvic and lumbo-aortic lymph node dissection. The pathological diagnosis was an ovarian pT4N1R0 squamous cell carcinoma. An adjuvant chemotherapy is still in progress.

A Mature Cyst Teratoma with Malignant Transformation in Squamous Cell Carcinoma Presenting Like a Sigmoid Fistula: A Case Report of a Rare Differential Diagnosis of a Giant Colonic Diverticulum

Mature cystic teratoma is the most common form of ovarian germ cell tumor. Mature cystic teratoma is a benign tumor, mainly diagnosed in young women, with non-specific symptoms. However, the risk of malignant transformation exists (1-2%). Squamous cell carcinoma is the most frequently encountered histological form. Giant colonic diverticulum is a rare complication of diverticular disease, characterized by a diverticulum larger than 4 cm which can sometimes be confused with other digestive pathologies (appendicitis, small bowel perforation ...). We report a case of an ovarian squamous cell carcinoma arising from a mature cystic teratoma, presenting like a sigmoid fistula, with an initial doubt with the diagnosis of a giant colonic diverticulum. A 68-year-old woman was admitted for chronic hypogastric abdominal pain with a doubt concerning the diagnosis between a mature cystic teratoma and a giant colonic diverticulum. A computed tomography scan was performed revealing a perisigmoid cyst with hydro-aeric level in favor of a giant colonic diverticulum. The pelvic MRI rather suggested a left ovarian cyst, fistulated in the sigmoid colon. Finally, the colonoscopy confirmed this hypothesis with the visualization of a sigmoid fistula located 15cm from the anal margin in connection with a cavity containing hairs. Biopsies revealed a squamous cell carcinoma. After a negative extension assessment, a posterior pelvectomy was performed with pelvic and lumbo-aortic lymph node dissection. The pathological diagnosis was an ovarian pT4N1R0 squamous cell carcinoma. An adjuvant chemotherapy is still in progress.

Analysis of risk factors for postoperative enterocutaneous fistula after inguinal hernia free tension repair

Objective To analyze the risk factors for postoperative enterocutaneous fistula after inguinal hernia free tension repair. Methods The retrospective case-control study was conducted. The clinical data of 679 patients who underwent inguinal hernia free tension repair between January 2015 and September 2018 in Beijing Chao-Yang Hospital of Capital Medical University were collected. There were 646 males and 33 females, aged (65±12)years, with a range from 28 to 94 years. Observation indicators: (1) surgical situations of inguinal hernia free tension repair; (2) follow-up; (3) enterocutaneous fistula and its treatment; (4) risk factors for postoperative enterocutaneous fistula after inguinal hernia free tension repair. Follow-up by outpatient examination and telephone interview was performed to detect the postoperative enterocutaneous fistula up to June 2019. Measurement data with normal distribution were represented as Mean±SD. Count data were described as absolute numbers. Univariate analysis and multivariate analysis were done using the chi-square test and Logistic regression model, respectively. Results (1) Surgical situations of inguinal hernia free tension repair: 679 patients underwent inguinal hernia free tension repair. Of 679 patients, 215 underwent plug repair or mesh-plug repair, including 9 cases undergoing Plug repair only, 50 undergoing Millikan procedure, and 156 undergoing Rutkow procedure, other 464 underwent non-plug surgery, including 181 undergoing Lichtenstein procedure, 53 undergoing transinguinal preperitoneal hernia repair (TIPP), and 230 undergoing transabdominal preperitoneal patch repair (TAPP) and total extraperitoneal inguinal hernia repair (TEP). Polypropylene mesh or plug were used in all 679 cases. The operation time and volume of intraoperative blood loss were (61±14)minutes and (10±7)mL. There were 580 of 679 patients treated with prophylactic antibiotics. (2) Follow-up: 679 patients were followed up for 15-86 months, with a median time of 51 months. There were 12 male patients with postoperative enterocutaneous fistula, aged (69±8)years, with a range from 57 to 79 years, twelve patients with enterocutaneous fistula developed symptoms within the time of (42±25)months. (3) Enterocutaneous fistula and its treatment: of 12 patients with enterocutaneous fistula, 11 underwent plug repair or mesh-plug repair, and 1 undergwent TAPP(enterocutaneous fistula secondary to invasion of preperitoneal patch to intestines). The fistulas were located at inguinal region, with a diameter of 0.5-1.0 cm. In the 12 patients, of the 5 patients with sigmoid fistula, 4 underwent intestinal resection around the fistula, 1 underwent distal bowel closure and proximal colostomy. Six patients had enteric fistula, including 5 secondary to invasion of plug to intestines and 1 due to preperitoneal patch in TAPP, and they underwent resection of intestines with fistula combined with side-to-side intestial anastomosis, or laparoscopic suture of all layers and seromuscular layer of enterocutaneous fistula. One patient with intestinal and vesical fistulas underwent resection of intestines with fistula, and had sutured and embeded them with 3-0 absorbable strings. Operation time of 12 patients was (126±40)minutes. Five patients received debridement and drainage for reoperation. Duration of hospital stay of 12 patients was (37±11)days. (4) Risk factors for postoperative enterocutaneous fistula after inguinal hernia free tension repair: results of univariate analysis showed that surgical method was associated factor for postoperative enterocutaneous fistula after inguinal hernia free tension repair (χ2=17.601, P<0.05). Results of multivariate analysis showed that plug repair or mesh-plug repair was an independent risk factor for postoperative enterocutaneous fistula after inguinal hernia free tension repair (odds ratio=32.279, 95% confidence interval: 4.027-258.735, P<0.05). Conclusion The plug repair or mesh-plug repair is an independent risk factor for postoperative enterocutaneous fistula after inguinal hernia free tension repair. Key words: Hernia; Inguinal hernia; Tension free repair; Plug; Enterocutaneous fistula; Risk factors

Laparoscopic-assisted proctocolectomy using complete intracorporeal dissection

Although many studies have demonstrated good results using laparoscopic proctocolectomy in patients with ulcerative colitis (UC), most surgical procedures require at least one additional incision larger than 5 cm to complete the surgery. The aim of this study was to evaluate the use of laparoscopic proctocolectomy with ileoanal J pouch, with a complete intracorporeal dissection using a 4-5 cm right lower quadrant (RLQ) incision. Data were collected prospectively from all patients with UC that were subjected to a proctocolectomy with ileoanal J pouch between August 2003 and December 2006. The dissection was performed completely by laparoscopy using a medial-lateral approach for the colon and a total mesorectal excision for the rectum. Once the rectum was resected laparoscopically, a 4-5 cm incision in the RLQ was performed to resect the specimen and then an end or a loop ileostomy was implanted at the RLQ wound. The surgery was performed in two (proctocolectomy with ileoanal J pouch and loop ileostomy) or three steps (subtotal colectomy and end ileostomy with sigmoid fistula; proctectomy with ileoanal J pouch; and loop ileostomy). A total of 47 surgical procedures were performed in 32 patients with a mean age of 34.5 +/- 15.7 years, of which 56% were male. The mean body mass index was 21 +/- 16 kg/m(2); 50% of patients underwent surgery in two steps and the other 50% in three steps. Surgery was converted in five (10.6%) cases due to megacolon in one case, narrow pelvis in two, and difficult rectal dissection in two; the overall morbidity rate was 14.9%. Two patients required reoperation and no mortality was registered. The mean operative time was 248 +/- 62 min; proctocolectomy 292 +/- 61 min, subtotal colectomy 203 +/- 43 min, and proctectomy 248 +/- 47 min. The mean hospital stay was 4.8 +/- 1.9 days, and the mean interval time to close loop ileostomies was 64 +/- 12 days. A complete laparoscopic proctocolectomy dissection is feasible and safe for surgical treatment of UC.

Sigmoid impaction secondary to urinary stones: case report and review of literature

Background This is the first case report of a Miami pouch sigmoid fistula developing passage of urinary stones resulting in the presentation of constipation secondary to impaction. Case report A 49-year-old woman who developed a recurrence of invasive squamous cell cervical carcinoma 1 year after pelvis radiation. She then underwent anterior pelvic exenteration and creation of a Miami pouch. Approximately 14 years after the primary radiation therapy and 13 years after the creation of the exenterative procedure, the patient developed a Miami pouch sigmoid fistula. The decision was made at this time to repair the fistula and remove the urinary stones from the sigmoid colon. Postoperatively, the patient remained continent using intermittent catheterization of the pouch and there was no evidence of recurrence of the cancer. Conclusion Conservative management of urinary reservoir complications should always be considered before surgical intervention is attempted. When indicated, surgical management should not be delayed.

Severe Radiation Injury to the Sigmoid Colon

We report our experience with the surgical management of severe radiation injury to the rectosigmoid colon. This was a retrospective chart review of patients cared for by the University of South Florida gynecologic oncologists over a 10-year period beginning July 1, 1985. Fifteen patients were identified. Five had a sigmoid stricture. Two of these underwent transverse loop colostomy, and the other three were managed with resection and an anastomosis with protective colostomy. Four patients had severe sigmoiditis, three of which were complicated by hemorrhage. Three of these underwent transverse loop colostomy, and the fourth underwent resection and anastomosis with protective colostomy. Three patients had a sigmoid fistula, with two undergoing transverse loop colostomy and the third undergoing resection and anastomosis with protective colostomy. There were two rectovaginal fistulas, both managed with transverse loop colostomy. One patient had free perforation of the sigmoid colon managed with transverse loop colostomy, and she died 4 weeks later. One patient who had been diverted for severe hemorrhagic proctosigmoiditis developed further bleeding 1 year later from the transverse colon. The transverse colon and colostomy were removed, and the remaining colon was anastomosed. All five patients who had a colorectal anastomosis had their colostomy taken down 2 1/2–8 months postoperatively. One developed a rectovaginal fistula and radiation enteritis 3 months later, necessitating replacement of the colostomy and a small bowel resection. The remaining four patients have done well 7–63 months following colostomy closure. Most cases of severe radiation injury of the rectosigmoid colon require a diverting colostomy. Patients with severe radiation sigmoiditis, sigmoid stricture, and even fistula are sometimes candidates for eventual restoration of intestinal continuity. (J GYNECOL SURG 12:191, 1996)

Vascular-enteric fistula: Diagnosis by colonoscopy

A 67-year-old man had a past history of abdominal aortic aneurysm repair in 1982 with an aortobifemoral graft. He was admitted to his local hospital on October 26, 1992 with a 2 week history of fever, chills and left lower leg swelling. He was found to be confused with a tender and swollen left calf. Blood cultures were positive for Bacteriodes species. He was started on antibiotics and heparinized for a presumed left leg thrombosis. The patient developed guaiac-positive stools and underwent upper endoscopy and barium enema, which were reportedly normal. ACT scan of the abdomen revealed a small quantity of air in the perigraft area on the left limb of the aortobifemoral graft. He was transferred to our hospital for further care on November 5, 1992. On examination he was found to be thin, afebrile, and confused. Abdominal examination was remarkable for absence of masses, no tenderness, and normal bowel sound. The rectal exam was normal with a negative guaiac test. Extremity exam revealed a tender swollen left calf which exhibited a 6 cm superficial ulcer with an erythematous margin. Laboratory data included BUN and creatinine of 13 and 1.3 mg/dl, respectively, a WBC of 18,000/ram 3 with 15,000/ mm 3 neutrophils and 700/mm 3 bands, a prothrombin time of 15 seconds, a partial thromboplastin time of 35 seconds and a normal UA. Chest x-ray showed small bilateral pleural effusions. A transjugular Greenfield filter was placed. A tagged WBC scan revealed increased uptake in the left limb of the graft. A diagnosis of infected aortobifemoral graft was made and the patient was scheduled for surgery. A repeat blood culture grewPseudomonas aeroginosa which prompted a GI consult to evaluate for a possible bowel source. Colonoscopy was performed on November 16 which revealed a 3 cm large foreign body in the sigmoid colon protruding through the wall and crossing the lumen (Fig. 1). No associated pulsation or bleeding was noted. A diagnosis of paraprosthetic sigmoid fistula was made and the patient underwent surgical graft removal and extra anatomic biaxillofemoral graft placement. A sigmoid colectomy with colostomy and Hart-

Operative treatment of Crohn's ileocolitis complicated by ileosigmoid and ileovesical fistulae.

Ileovesical and ileosigmoid fistulae were found to coexist in 22 patients with Crohn's ileocolitis. Persistent or recurrent urinary tract infection was a complaint in all cases, and 11 patients reported pneumaturia and/or fecaluria. Thus, bladder involvement was either suspected or clinically apparent in each patient. The cystogram was the best confirmatory test for the ileovesical fistula (positive in 9 of 22 patients). The coexistence of the sigmoid fistula was best diagnosed on intestinal radiographs (positive in 9 of 22 patients); there were no clinical signs of its presence. The coexistence of ileosigmoid and ileovesical fistulae was the sole indication for operation in two patients. In all others, a combination of factors required surgical therapy. An ileocolonic resection with primary intestinal anastomosis was performed in 16 patients and exteriorization was performed in six patients. The sigmoid defect was closed primarily in 16 patients and required wedge resection in the other six patients. The bladder defect was sparingly excised and closed with absorbable sutures. All patients recuperated without anastomotic leaks, bladder leaks, or persistent cystitis. This experience indicates that coexisting ileosigmoid and ileovesical fistulae may add complexity to an ileocolonic resection for Crohn's disease, but is not a difficult management problem for the gastrointestinal surgeon.