Fistulizing Crohn's disease

Fistulas are common in Crohn's disease. A population-based study has shown a cumulative risk of 33% after 10 years and 50% after 20 years. Perianal fistulas were the most common (54%). Medical therapy is the main option for perianal fistula once abscesses, if present, have been drained, and should include antibiotics (both ciprofloxacin and metronidazole) and immunomodulators. Infliximab should be reserved for refractory patients. Surgery is often necessary for internal fistulas.     

The natural history of fistulizing Crohn's disease in Olmsted County, Minnesota

BACKGROUND & AIMS: Little is known about the cumulative incidence and natural history of fistulas in Crohn's disease in the community. METHODS: The medical records of all Olmsted County, Minnesota residents who were diagnosed with Crohn's disease from 1970 to 1993 and who developed a fistula were abstracted for clinical features and outcomes. Six patients denied research authorization. The cumulative incidence of fistula from time of diagnosis was estimated by using the Kaplan-Meier product-limit method. RESULTS: At least 1 fistula occurred in 59 patients (35%), including 33 patients (20%) who developed perianal fistulas. Twenty-six (46%) developed a fistula before or at the time of formal diagnosis. Assuming that the 9 patients with fistula before Crohn's disease diagnosis were instead simultaneous diagnoses, the cumulative risk of any fistula was 33% after 10 years and was 50% after 20 years (perianal, 21% after 10 years and 26% after 20 years). At least 1 recurrent fistula occurred in 20 patients (34%). Most fistulizing episodes (83%) required operations, most of which were minor. However, 11 perianal fistulizing episodes (23%) resulted in bowel resection. CONCLUSIONS: Fistulas in Crohn's disease were common in the community. In contrast to referral-based studies, only 34% of patients developed recurrent fistulas. Surgical treatment was frequently required.     

Retrospective analysis of arteriovenous fistula patency and failure in patients on dialysis for end-stage kidney disease in the Gaza strip

Background

The preservation of patent, well-functioning arteriovenous fistulas is one of the most difficult clinical problems in the long-term management of patients undergoing renal dialysis. This study aimed to define the patency and failure rates of fistulas in patients with end-stage kidney disease on dialysis and to examine how fistula failure is managed.

Crohn''s Disease of the Colon

The development of internal fistulas, fistulous tracts or external fistulas is extremely common in Crohn's disease of the colon occurring in 39% of patients in this series.
Fistulas, which usually originate in small bowel, particularly internal fistulas, are more common in ileocolitis. Nevertheless, in this series, a significant number, 23% of all fistulas (excluding anorectovaginal fistulas) and 37.5% of external fistulas, commenced in diseased colon.
Patients with such fistulas tend to have a more complicated course; with a significantly higher incidence of intraabdominal abscess formation and in granulomatous colitis, a higher incidence of extraintestinal complications.
Surgical intervention was required significantly more often in fistula patients than in the control series (82% vs. 49%).
The number of external fistulas following by-pass is significantly greater than that following resection (P < 0.01).     

Clinical course of perianal fistulas in Crohn's disease.

The clinical course of perianal fistulas and associated abscesses was evaluated prospectively in 90 patients with Crohn's disease. Fistula type, rectal disease, faecal diversion, and immunosuppression were examined as prognostic indicators for fistula healing and recurrence. Median follow up was 22 months. The outcome was evaluated with life table analysis. Prognostic factors were analysed by multiple regression. Inactivation was achieved in all patients. The risks of recurrent fistula activity were 48% at one year and 59% at two years. Fistulas were healed in 51% after two years but reopened in 44% within 18 months of healing. Faecal diversion and absence of rectal disease decreased recurrence rates (p = 0.019/0.04) and increased healing rates (p = 0.005/0.017). The outcome in patients with trans-sphincteric fistulas was better than that in those with ischiorectal fistulas but worse than in patients with subcutaneous fistulas (p = 0.015 for healing; p = 0.007 for recurrent fistula activity). After initial treatment about 20% of the patients were symptomatic and about 10% had painful events per six month period. Incontinence was rare and did not increase during the study period. Perianal fistulas and associated abscesses can be controlled safely by simple drainage of pus collections. Frequent reinfection and re-opening after healing of fistulas are characteristic. Fistula type, rectal disease, and stool contamination influence the clinical course. Only a few patients, however, have continuous symptoms from perianal fistulas.     

Transcatheter treatment of iatrogenic brachiocephalic‐jugular arteriovenous fistula and aortopulmonary artery fistula: A case report

Iatrogenic arteriovenous fistula is not a common complication of central venous catheterization. Duct occluder devices have been developed for patent ductus arteriosus occlusions but they may be used for arteriovenous fistula closures. We report a case of iatrogenic brachiocephalic‐jugular and aortopulmonary artery fistulas after central venous catheter insertion. The fistulas were successfully managed with duct occluder devices. Due to increasing number of central venous catheterizations, physicians should be aware of this uncommon complication. Transcatheter closing of brachiocephalic‐jugular and aortopulmonary artery fistulas by duct occluder devices seems to be a safe and feasible form of treatment. © 2013 Wiley Periodicals, Inc.     

Treatment of peri-anal fistula in Crohn’s disease

Anal fistulas are a common manifestation of Crohn’s disease(CD). The first manifestation of the disease is often in the peri-anal region, which can occur years before a diagnosis, particularly in CD affecting the colon and rectum. The treatment of peri-anal fistulas is difficult and always multidisciplinary. The European guidelines recommend combined surgical and medical treatment with biologic drugs to achieve best results. Several different surgical techniques are currently em-ployed. However, at the moment, none of these tech-niques appear superior to the others in terms of healing rate. Surgery is always indicated to treat symptomatic, simple, low intersphincteric fistulas refractory to medi-cal therapy and those causing disabling symptoms. Ut-most attention should be paid to correcting the balance between eradication of the fistula and the preservationof fecal continence.     

Duodenal fistulas in Crohn's disease

Of 1,480 patients with Crohn's disease admitted to The Mount Sinai Hospital between 1960 and 1983, eight (0.5%) had duodenal fistulas (DF), all originating from diseased small or large bowel and not from primary disease of the duodenum. The extent, duration, and major clinical features of Crohn's disease did not differ between patients with DF and those with other fistulas. Six of the patients underwent surgery for refractory disease or abscess formation and two patients were treated medically. All improved and were able to maintain an adequate oral intake after treatment. At follow-up 3-10 years later, the surgically treated patients were well but both medically treated patients had died, one from a probably unrelated brain tumor 7 years after discharge and one from necrotizing pancreatitis 10 years later. Our experience suggests that the presence of a DF is not an absolute indication for early surgery. The initial therapeutic management of such patients should be determined by the nature and severity of the underlying Crohn's disease rather than the presence of a DF. The late pancreatic complication in a patient with a chronic DF, however, raises the question of an association between the two.     

自体脂肪干细胞移植治疗复杂性肛瘘的临床观察

目的评估自体脂肪干细胞移植治疗复杂性肛瘘的有效性和安全性。 方法纳入2018年1月到2018年10月间南京市中医院肛肠中心收治的复杂性肛瘘23例,年龄12~51岁,其中克罗恩病肛瘘11例,腺源性肛瘘12例,应用自体脂肪干细胞移植治疗,随访3~12个月,并收集患者的临床资料。通过临床评估及MRI结果评价瘘管闭合情况,统计瘘管外口完全上皮化的时间,采用SF-36量表和VAS量表评估患者术前、术后的生活质量变化及疼痛评分变化,运用Wexner失禁评分量表评估患者术前术后的肛门失禁情况,对于克罗恩病肛瘘患者需记录其治疗前后的肛周病变活动指数（PDAI）,并记录研究中的所有不良事件。 结果瘘管的总愈合率为69.57%（16/23）,其中克罗恩病肛瘘的愈合率为90.91%（10/11）,腺源性肛瘘为50%（6/12）;16名瘘管愈合患者的外口平均闭合时间为（17.06±4.54）天,其中克罗恩病肛瘘为（17.90±4.53）天,腺源性肛瘘为（15.67±4.59）天。患者的生活质量评分与疼痛评分在术后7天可恢复至术前水平,而肛门失禁评分则保持不变或降低。克罗恩病肛瘘患者治疗前和治疗后90天的PDAI评分为（8.55±1.37）分和（1.27±1.10）分,二者之间差异有统计学意义（t=12.033,P<0.05）。研究中未出现与ADSCs注射相关的不良事件。 结论自体脂肪干细胞移植是治疗复杂性肛瘘特别是克罗恩病肛瘘的一种安全有效的方法,可以保护患者肛门功能,减轻术后疼痛,改善围手术期生活质量。     

Combined endoscopic cautery and clip closure of chronic gastrocutaneous fistulas

BACKGROUND: Chronic gastrocutaneous fistula with intermittent drainage is a common outcome after removing long-standing gastrostomy tubes. The standard treatment is surgery with laparotomy and excision of the fistula tract. This study describes the results of an endoscopic closure technique by using a combination of electrocautery and metal clips. METHODS: Three patients with gastrocutaneous fistulas (duration 3 months to 3 years) after gastrostomy tube removal were treated endoscopically by electrocautery of the tract and application of metal clips. OBSERVATIONS: Treatment resulted in complete fistula closure in two patients and partial closure in a third patient. CONCLUSIONS: Combined endoscopic therapy with electrocautery and clipping may be an alternative to surgical closure of chronic gastrocutaneous fistulas.     

Recent advances in the treatment of air leaks

PURPOSE OF REVIEW: Alveolar-pleural fistulas (air leaks) are an extremely common clinical problem and remain the most common complication after elective pulmonary resection and video-assisted procedures. The decision making process used to manage air leaks and chest tubes that control them has been, until very recently, based on opinions and training preferences as opposed to facts derived from randomized clinical trials. RECENT FINDINGS: Recently, several prospective randomized trials have studied air leaks. An objective, reproducible classification system has also been designed and clinically validated to help study air leaks. This system and these studies have shown that water seal is superior to wall suction to help stop most leaks. Even in patients with a pneumothorax and an air leak, water seal is safe and best; however, if a patient has a large leak (greater than an expiratory 3 on the classification system) or experiences subcutaneous emphysema or an expanding pneumothorax that causes hypoxia, then some suction (-10 cm of water) should be applied to the chest tubes. SUMMARY: Air leaks were a poorly understood yet extremely common clinical problem that had never been scientifically studied. Over the past 5 years, prospective randomized studies have shown that water seal is the best setting for chest tubes and that a pneumothorax is not a contraindication to leaving tubes on seal. Further studies are needed to investigate the ideal management of alveolar-pleural fistulas (air leaks) in different clinical scenarios besides those that occur postoperatively.     

Simple rectovaginal fistulas

In regard to the causes of simple rectovaginal fistulas (RVF) we examined the methods of diagnosis and the efficacy and outcome of surgical procedures. The study included all of our patients diagnosed with simple RVF between December 1988 and July 1998 (n = 19). Medical charts of these patients were reviewed regarding diagnostic investigations, operative procedure, outcome, and follow-up. The most common cause was obstetric trauma (n = 15, 79%) followed by infection (n = 4, 21%). Eight patients (42%) had undergone anal surgery prior to the development of RVF; two of these had undergone more than one procedure. Endoanal ultrasound was performed in 15 patients and identified the fistula in 11 (73%). A concomitant sphincter injury was visualized in 9 of 15 patients (60%). The most common initial operation performed was an endoanal advancement flap in 12 patients (63%). This operation was performed in combination with a sphincteroplasty in 4 patients, while 3 had sphincteroplasty alone. The mean hospital stay was 3 days (range 1-5). Postoperative morbidity was noted in 5 patients (26%) of and consisted of recurrent fistula and passage of gas per vagina. Surgery was successful in complete resolution of symptoms in 14 cases (74%). Two of the three recurrences were successfully repaired with a repeat endoanal advancement flap, and one is awaiting repair. The mean follow-up for the entire group was 35.8 months (range 6-84). Endoanal advancement flap should be the initial treatment of choice for simple, low rectovaginal fistulas. The procedure can also be employed with expectations of success even after a failed primary repair and should be combined with sphincteroplasty if a coexistent anteriorly based anal sphincter defect is noted either by clinical examination or endoanal ultrasonography.     

Long-term success rate after surgical treatment of anorectal and rectovaginal fistulas in Crohn’s disease

Background  Due to the considerable variety in the clinical presentation of anorectal and rectovaginal fistulas in Crohn’s disease, data on treatment results for each type of fistula are limited. The aim of this study was to summarize the results after surgical treatment of such fistulas in a large consecutive series of patients. Patients and methods  All patients with anorectal or rectovaginal fistula due to Crohn’s disease requiring surgery in our institution between 1991 and 2001 were extracted from a prospective database. A standardized telephone interview was conducted and patients were followed in our outpatient clinic, the department of internal medicine, or at their gastroenterologist. Type of fistula and interventions were classified and analyzed. Recurrence-free time intervals were estimated for each type of fistula and for the different surgical procedures. The influence of the surgical procedure, the number of operations performed, and the correlation to other localizations of the disease were analyzed in regard to the recurrence rate. Results  From 777 patients with Crohn’s disease undergoing surgery between 1991 and 2001, 147 had anorectal or rectovaginal fistula (292 operations). Ninety-eight percent of them also had Crohn’s disease in the colon or rectum compared to only 21% of patients without a fistula (p value <0.001). Over long-term follow-up, 29 patients (20%) required proctectomy. Submucosal fistulas needed major surgery in only 14% of cases compared to 56% of cases with rectovaginal fistulas. After 5 years, complex fistulas showed a strong trend towards a higher recurrence rate after surgery than simple submucosal fistulas (45.6% vs. 18.8%, p = 0.079). Whereas recurrences occurred over the whole observation period in the group of patients with complex fistulas, there was no further recurrence in patients with submucosal fistulas 13 months after surgery. In rectovaginal fistulas, additional levatorplasty showed no advantage over standard endorectal advancement flap. Conclusions  Long-term follow-up demonstrates that recurrence rates after repair of complex fistulas for Crohn’s disease are high and continuously increase over time. Submucosal fistulas have the best outcome; after 13 months without recurrence, definite cure can be expected.     

Tuberculous anal sepsis

INTRODUCTION: Tuberculosis is a neglected cause of anal sepsis, often is not recognized, and therefore is not treated properly. METHOD: All patients were reviewed who had tuberculous anal sepsis diagnosed by histology reports of fistulectomy specimens or abscess scrapings from January 1990 to April 1999. RESULTS: Twenty patients (median age, 53 years; 18 males) with anal tuberculous sepsis were identified. They presented with abscesses (n=2), abscesses and fistulas (n=6), or fistulas (n=12). All patients had a long history of anal complaints (3 months to 20 years), for which 15 patients were operated on previously. Nearly all fistulas (17/18) were complex, and secondary tracks or additional complicating features were common, even at first presentation. Eight patients had active concurrent pulmonary tuberculosis, and six showed evidence of previous pulmonary tuberculosis. Six patients had no signs of concurrent or previous tuberculosis elsewhere. Recurrence was observed only in cases where tuberculosis was initially not recognized, and antitubercular treatment therefore was not started. CONCLUSION: Contrary to views held previously, anal tubercular sepsis seems to have characteristic clinical features. It should be considered in cases of known pulmonary or extrapulmonary tuberculosis or if anal sepsis is persistent, recurrent, or complex in nature.     

Coronary artery fistula after heart transplantation: A disappearing entity?

A high incidence of coronary artery fistulas has been observed angiographically after heart transplantation. To determine the present incidence of this finding and the natural history of fistulas in this setting, we reviewed coronary angiograms and clinical course on all patients (n = 480) transplanted from 1980 to 1990 who survived until the first annual coronary angiogram and compared the incidence of coronary artery fistulas in the early (patients #1–160), middle (patients #161–320), and late transplant (patients #321–480) groups. The 3-yr coronary artery fistula incidence for the early group was 8.5%, 6.9% for the middle group, and 2.9% in the late group (P < 0.05, early vs late). Patients who developed fistulas were followed longitudinally. Angiographic follow-up data (median duration: 6 years) were available in 14 patients having 17 fistulas. No fistula increased in size, and in 10 of 14 patients (71%), fistulas became angiographically undetectable. No patient had any clinical complication related to the fistula. In summary, the incidence of coronary artery fistulas is presently lower than previously reported, which may in turn be related to refinements in heart biopsy technique. The lack of long-term clinical sequelae and the relatively high rate of disappearance favor a conservative approach of “watchful waiting.” © 1996 Wiley-Liss, Inc.     

Formalin irrigation for hemorrhagic chronic radiation proctitis

AIM: To assess the efficacy and safety of a modified topical formalin irrigation method in refractory hemorrhagic chronic radiation proctitis(CRP). METHODS: Patients with CRP who did not respond to previous medical treatments and presented with grade II-III rectal bleeding according to the Common Terminology Criteria for Adverse Events were enrolled. Patients with anorectal strictures, deep ulcerations, and fistulas were excluded. All patients underwent flexible endoscopic evaluation before treatment. Patient demographics and clinical data, including primary tumor, radiotherapy and previous treatment options, were collected. Patients received topical 4% formalin irrigation in a clasp-knife position under spinal epidural anesthesia in the operating room. Remission of rectal bleeding and related complications were recorded. Defecation, remission of bleeding, and other symptoms were investigated at follow-up. Endoscopic findings in patients with rectovaginal fistulas were analyzed.RESULTS: Twenty-four patients(19 female, 5 male) with a mean age of 61.5 ± 9.5 years were enrolled. The mean time from the end of radiotherapy to the onset of bleeding was 11.1 ± 9.0 mo(range: 2-24 mo). Six patients(25.0%) were blood transfusion dependent. The median preoperative Vienna Rectoscopy Score(VRS) was 3 points. Nineteen patients(79.2%) received only one course of topical formalin irrigation, and five(20.8%) required a second course. No side effects were observed. One month after treatment, bleeding cessation was complete in five patients and obvious in14; the effectiveness rate was 79.1%(19/24). For longterm efficacy, 5/16, 1/9 and 0/6 patients complained of persistent bleeding at 1, 2 and 5 years after treatment, respectively. Three rectovaginal fistulas were found at 1 mo, 3 mo and 2 years after treatment. Univariate analysis showed associations of higher endoscopic VRS and ulceration score with risk of developing rectovaginal fistula. CONCLUSION: Modified formalin irrigation is an effective and safe method for hemorrhagic CRP, but should be performed cautiously in patients with a high endoscopic VRS.     

Complete Closure of Cancer-Related Anovaginal and Anoperineal Fistulas in Locally Advanced Anal Canal Carcinomas by Upfront Intra-Arterial Chemotherapy Followed by Combined Radiochemotherapy: Report of Two Cases

Purpose Cancer-related fistulas are a major problem in locally advanced anal canal carcinoma, because conservative radiochemotherapy may not be recommended in this setting. Therefore, it is usually recommended to proceed to an abdominoperineal resection with definitive colostomy in the presence of such lesions. Methods Because chemotherapy can lead to closure of cancer-related fistulas and local intra-arterial chemotherapy is effective in locally advanced anal canal cancer, we treated two anal canal carcinoma patients presenting with cancer-related fistulas with upfront intra-arterial chemotherapy followed by radiochemotherapy, leading to complete closure of fistulas. Results Both patients are free of colostomy and in complete remission after more than four years of follow-up. Conclusions This conservative approach combining local intra-arterial chemotherapy and standard radiochemotherapy is feasible and should be considered in the management of such locally advanced anal canal carcinoma. Reprints are not available.     

Colocutaneous fistulas complicating diverticulitis

The records of 93 patients with colocutaneous fistulas associated with diverticulitis treated at the Cleveland Clinic between 1965 and 1983 were reviewed. There were 56 males and 37 females with an age range of 19 to 80 years (median, 57 years). Eighty-eight fistulas followed surgery for diverticulitis while five developed spontaneously. The presence of a diverting stoma in 34 patients did not prevent fistula formation but did decrease morbidity (x²=12.75,P<0.001). Initial investigations showed a high incidence of recent weight loss (in 40 percent) and hypoalbuminemia (47 percent), although these factors did not influence outcome. Patients with high output (>200 cc/day) fistulas) (n=9) fared significantly worse than those with low outputs. There were 28 patients with fistulas to other organs, 20 involving small bowel. Factors leading to persistence of the fistulas included sepsis (42 cases) and sigmoid colon distal to an intended colorectal anastomosis (38 cases). Ninety-two patients underwent surgery, 80 percent having a one-or two-stage resection and anastomosis. There was one postoperative death and complications occurred in 44 patients (48 percent). Surgery was successful in producing patients without stoma or fistula in 71 cases (77 percent). There were five recurrent fistulas, 14 new fistulas, and 13 patients retained their stomas. A diagnosis of Crohn's disease was made in ten patients who had a high rate of complicated fistulas, recurrent fistulas, and retained stomas. Patients with carcinomas (n=5) also did poorly, but those on systemic steroids (n=7) fared no worse than patients not receiving them. This study emphasizes the role of diversion of the fecal stream in reducing the morbidity of colonic fistulas. It is clearly important to carry out a truecolorectal anastomosis after resection for diverticulitis, and in patients with unusually complicated clinical courses, the diagnosis of Crohn's disease should be entertained. Read at the meeting of the American Society of Colon and Rectal Surgeons, Houston, Texas, May 11 to 15 1986.     

Die chirurgische Behandlung des anorektalen Abszesses

Treatment of anorectal suppuration includes timely and sufficient surgery. So later complications like fistula-in-ano can be ruled out. In this prospective study the data of 324 patients who had been operated because of an anorectal suppuration were examined. 38,6% of these abscesses were located in the perianal tissue, 34.6% in the intersphincter space, 19,4% in the ischiorectal fossa and 7,4% in the supralevator space. Only in 25,6% patients who were operated an anal fistula was proved. In ischiorectal abscesses we found fistula-in-ano within 47,6% of the patients, in most cases trans- and suprasphincteric fistulas. 62.1% of these patients did not need further interventions. Sixteen of 45 intraoperative diagnosed trans- and suprasphincteric fistulas did not need further operative interventions (35.6%). At 7.7% later diagnosed fistulas had to be treated operatively. 9.6% of the patients developed a new suppuration. The renunciation of an intensive primary fistula search doesnt lead to a higher persisting fistula formation. From this aspect a further exploration should be renounced in the first operation. Of course superficial fistulas can be cured in the same meeting. From this point a drainage cutting-seton should be viewed very critically. Postoperativ diagnosed high anal fistulas can be treated after fading of acute infection with continent fistulectomy.