Small bowel enterocutaneous fistulae: the merits of early surgery

Background

The treatment of patients with small bowel enterocutaneous fistulas is complex and a challenge for every surgeon. The mortality and morbidity associated with only conservative management is often high and expensive because most patients cannot afford prolonged parenteral nutrition which itself carries a high incidence of complications. Although operations are difficult if performed early they may be lifesaving in our situation. The focus of our study was to determine whether, in patients with fistulae, early intervention resulted in low mortality and morbidity rates and to identify prognostic factors for fistula closure and mortality.

Patients and methods

Between August 1996 and July 2008 we treated 64 consecutive patients with small bowel enterocutaneous fistulae. There were 28 females and 36 males patients who had a mean age of 42.4 years. 49 (77%) of the fistulae resulted from surgical complications. Our policy was to intervene early once the patient was fit for a procedure.

Results

In 4 patients (6.2%) the fistulae arose from the jejunum and in the remaining 94% from the ileum. Octreotide was administered in 49 (77%) patients. To maintain the nutrition of the patients enteral feeding was used in 47 (73%) while re-feeding of the proximal gut fistula output into the distal stoma was used in 7 patients. Spontaneous closure occurred in 10 patients (16%). There were 9 deaths (14%). Fifty-two patients (81%) required surgical intervention at some stage. A strong relationship was found between their preoperative albumin levels and and mortality.

Conclusion

Aggressive early surgical treatment with the judicious use of nutritional support, stoma care, octreotide, and control of sepsis results in a low mortality in patients with small intestinal fistulae. Preoperative hypoalbuminaemia is an important prognostic variable.     

Current management of enterocutaneous fistula

Enterocutaneous fistulas, defined as abnormal communications between bowel and skin, are among the most challenging conditions managed by the general surgeon. In an era when the mortality from pan-creaticoduodenectomy is less than 3%, the mortality of enterocutaneous fistulas remains 10 to 30% due to the often-present complications of sepsis, malnutrition, and electrolyte abnormalities. Taking ad-vantage of recent advances in techniques of pre- and post-surgical management and support, employing a multidisciplinary team approach, and executing a well-delineated management plan provide the patient and surgeon with the best possibility of success in treating this potentially devastating condition.     

A retrospective review of chronic anal fistulae treated by anal fistulae plug

Objective The aim of this study was to analyse the efficacy of the anal fistulae plug (Cook Surgisis® AFP?) for the management of complex anal fistulae. Method A review of patients with anal fistulae treated using Cook Surgisis® AFP? between October 2005 and 2007 was undertaken. Patient’s demographics, fistulae aetiology and success rates were recorded. Results Thirty‐three patients underwent 49 plug insertions. The median age was 44.4 years; 18 females. The fistulae aetiology was cryptoglandular in 61% and Crohn’s disease in 39%. The median follow up 221.5 days (range 44–684). Twenty‐one patients had previous failed surgery. Twenty‐eight patients had draining setons in situ at time of plug placement. The overall success rate was 8/32 patients (25%). Two of the 22 Crohn’s fistulae healed (9.1%) and 9/26(34.6%) cryptoglandular fistulae healed. The reasons for failure were sepsis in 87% and plug dislodgement in 13%. Significant predictor factors for improved outcome were African‐Americans patients (P = 0.009), and presence of seton (P = 0.05). Conclusions Anal fistulae plug was associated with a lower success rate than previously reported. Septic complications were the main reason for failure.     

纤维蛋白胶封堵法治疗肠外瘘32例报告

目的探讨纤维蛋白胶封堵法治疗肠外瘘临床应用价值。方法2003年2月至2006年2月第二军医大学附属长海医院对32例术后肠外瘘病人应用纤维蛋白胶封堵法治疗肠外瘘,观察其临床疗效。结果31例获得愈合,封堵开始至愈合平均时间(8.9±3.6)d,平均封堵次数(2.3±1.3)次,其中1次者11例,2次者9例,3次及以上者12例,成功率为96.9%。结论纤维蛋白胶能有效地促进肠外瘘愈合。     

Continuous reinfusion of succus entericus associated with fistuloclysis in the management of a complex jejunal fistula on the abdominal wall

INTRODUCTIONFistuloclysis is an alternative method for enteral nutrition infusion, and has been successfully employed for the management of patients with high output small bowel fistula. However it has some deficiencies also.PRESENTATION OF CASEA 42-year-old woman with multiple high output enterocutaneous fistula was submitted to fistuloclysis with reinfusion of chyme, after a period of several complications due to parenteral nutrition.DISCUSSIONEnteral nutrition provide better nutrition and fewer complications than parenteral nutrition. The enterocutaneous fistula usually does not allow enteral nutrition, however the use of fystuloclysis can fix this issue. The reinfusion of chyme provide the possibility of oral intake and better control of hydroeletrolitics disorders.CONCLUSIONMore studies on the physiological effects of the chyme recirculation could add more data contributing to the clarification of this complex issue, but we believe that patients with high output and very proximal enterocutaneous fistula can be sucessfully treated with fistuloclysis and recirculation of chyme.     

Vesicouterine fistulae as complications of repeated cesarean section

In all, only 167 cases of vesicouterine fistula have been documented in the world medical literature to date. In this paper the authors report five cases observed during the last 10 years, all secondary to cesarean section. It was the second operation for 3 patients and the third for the other 2. Two patients had urinary incontinence and 3 had amenorrhea and cyclic hematuria. The authors confirm the importance of conducting adequate investigations to ensure proper diagnosis of the fistula, and describe the choice of surgical approach.     

Nonthyroidal illness syndrome in enterocutaneous fistulas

Background

The aim of this study was to investigate the incidence, etiology, clinical outcomes, and prognosis of nonthyroidal illness syndrome (NTIS) in patients with enterocutaneous fistulas.

Methods

We prospectively collected 226 patients with enterocutaneous fistulas. Demographics, Acute Physiology and Chronic Health Evaluation II (APACHE II) and Sequential Organ Failure Assessment scores, C-reactive protein, body mass index, albumin, and thyroidal hormones were evaluated for each patient.

Results

The incidence of NTIS was 57.5% in patients with enterocutaneous fistulas. Age and the APACHE II and Sequential Organ Failure Assessment scores were significantly higher, whereas albumin was lower in the NTIS group compared with those in the euthyroid group. A decreased sum activity of deiodinases and a reduced ratio of total thyroxin/free thyroxin and total triiodothyronine/free triiodothyronine were observed in the NTIS group. Patients with NTIS suffered longer durations in the intensive care unit and higher possibilities of mechanical ventilation. The cumulative survival rate was significantly lower in the NTIS group.

Conclusions

NTIS was common, and patients with NTIS displayed worse clinical outcome and prognosis. A hypodeiodination condition and a potential thyroid hormone–binding dysfunction may play a role in the etiology of NTIS. A low serum albumin concentration and a high APACHE II score were risk factors of NTIS in enterocutaneous fistulas.     

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目的：观察肠外瘘病人入院初期人体组成成分的连续性变化。方法：采用多频生物电阻抗分析仪观察61例肠外瘘病人在入院10天内人体组成与血浆蛋白的变化。结果：病人体质指数与体细胞群在观察期间均有改善，但只有后者差异具显著性，而细胞外水／总体水的比例快速敏感地降至正常水平。血浆蛋白水平虽有提高，但只有前白蛋白差异具显著性。结论：肠外瘘病人入院后早期营养支持可快速改善水分分布的异常，并可以阻止体细胞群的进一步分解消耗。     

肠外瘘外科分型的CT表现

目的探讨肠外瘘分型的CT表现。方法对754例肠外瘘进行CT检查。参照临床分型．将肠外瘘分为管状瘘和唇状瘘2个类型，分别分析它们的CT征象。结果本组管状瘘518例（68．6％）．其CT征象为内、外口之间形成不均匀的管道；唇状瘘236例（31.4％），其CT征象特点是较大的外口呈唇状改变。肠外瘘的肠管和腹腔内改变表现为炎性病灶，其中管状瘘的腹腔和腹膜后脓肿发生率明显高于唇状瘘（P〈0．01），而唇状瘘的肠壁炎性改变发生率较高（P〈0．01）。结论肠外瘘具有特征性CT表现，CT检查有助于显示肠外瘘外科分型的影像学征象。     

Fibrin glue in the management of anal fistulae

OBJECTIVE: Fibrin glue has been used as a sphincter sparing approach for the treatment of anal fistulae for two decades. However, there is uncertainty about its short and long-term efficacy. The objective of this review was to ascertain the role of fibrin glue in the management of anal fistulae, including assessment of recurrence rates, continence disturbance and other complications. METHODS: We searched Medline (January 1966 to February 2004), the Cochrane database, and EMBASE using the terms anal fistulae, fistula-in-ano, and fibrin glue. Relevant papers from the reference lists of these articles and from the authors' personal collections were also reviewed. A systematic review of all articles relating to the use of fibrin glue in the treatment of anal fistulae was performed. This included 19 studies. Reviewers performed data extraction independently. Outcomes evaluated included recurrence rates, continence disturbance, septic complications, adverse drug reactions, and duration of follow-up. Heterogeneity of the clinical trials made direct comparisons difficult and meta-analysis impossible. RESULTS: The success rates reported in published studies range from 0% to 100%. Differences in patient selection (including fistula aetiology and type), treatment protocols, and follow-up duration may contribute to such diverse results. CONCLUSIONS: Fibrin glue is simple to use, has a minimal morbidity and should not affect later treatment options in the event of its failure. It is therefore theoretically attractive as a first line treatment in the management of those types of anal fistula in which it has been shown to work. However, further research into 'biological' glues is merited and these subject to randomised controlled study.     

Laparoscopic resection of diverticular fistulae: a 10-year experience

OBJECTIVE: Until recently the laparoscopic approach was reserved for uncomplicated diverticular disease. We show that fistulating diverticular disease can be resected safely, with good clinical outcome via a laparoscopic approach. METHOD: Between April 1994 and May 2005, 31 consecutive patients [17 male, median age of 63 years (range 40-85)], underwent attempted laparoscopic resection for diverticular fistulae. Patient data were prospectively recorded. RESULTS: There were 22 colovesical and nine colovaginal fistulae. The median operative time was 150 min (range 60-310) and the median postoperative stay was 7 days (range 3-21). Conversion to an open procedure was required in nine of 31 patients (29%). This rate fell to 10% in cases performed after April 2000. There were two nonsurgically related postoperative deaths. Both occurred in the converted group. At 3 months follow-up, two patients complained of frequency of stools, which settled by 6 months. To date there has been no recurrence of symptomatic diverticulosis or fistulation. CONCLUSION: Totally laparoscopic resection for diverticular fistulae is safe and feasible. Fistulae should not be considered as a contraindication to laparoscopic resection for an experienced laparoscopic surgeon.     

Split-shot sinker facilitates seton treatment of anal fistulae

Objective  The cutting seton is an inexpensive and effective method of treating high complex perianal fistulae. Following placement of the seton, advancement through the external sphincter muscles requires progressive tightening of the seton. The requirement for maintaining the appropriate tension and onset of perianal pressure necrosis are problems frequently encountered using this technique.
Method  Using a 3-0 polypropylene suture, a red-rubber catheter, and a nontoxic tin split-shot sinker, we minimized or eliminated these problems.
Results  We initially used this technique in one patient with satisfactory results.
Conclusion  This technique is technically easy, safe, inexpensive, and efficient, and we are using it in all patients with high perianal fistulae who require a seton.     

Transvaginal repair of vesicocervical fistulae — A forgotten method by Volkovich-Küstner?

The vaginal approach to vesicocervical fistulae by N. Volkovich [1] and O. Küstner [2] was characterized by the use of an artificial uterine descensus to achieve collapse and cushioning of the bladder defect. Over the past 35 years, this principle has been applied to 22 vesicouterine fistulae on 12 occasions. The technique is described in detail. Separation of the fistular canal is today followed by closure of the tract in both the bladder and the cervix. Sometimes, interposition of peritoneum was added (n=6). The method was primarily suitable for uncomplicated vesicocervical fistulae (n=4) or for vesicocervicovaginal fistulae (n=8) with the uterine corpus still present and to be preserved. However, if subtotal hysterectomy had been performed before (n=6), transvaginal extirpation of the remaining cervix and a bladder repair would be necessary. On the other hand, vagino-abdominal hysterectomy and bladder repair were unavoidable in cases of vesicocervicocorporeal fistulae (n=3) and in 1 case of vesicocervicovaginal fistula with a severely distorted cervix. Therapy was successful in all cases.     

Pancreatic abscess: 10 years experience

Background: Secondary infections of pancreatic and peripancreatic necrosis account for most of the deaths following acute pancreatitis. These infections occur in the form of ‘infected pancreatic necrosis’ and ‘pancreatic abscess’. The latter is a rare complication of acute pancreatitis in comparison with the former. Methods: Twenty‐one patients with pancreatic abscess were managed over a 10‐year period at a tertiary care centre in Northern India. The present report details the clinical profile, investigations performed and management strategy (surgery and intervention radiology) of these patients. The role of surgery and percutaneous catheter drainage (PCD) in the management of pancreatic abscess is discussed, with emphasis on the successful outcome seen in a properly selected group of patients managed by PCD. Results: Of the 21 patients, 12 were managed by percutaneous intervention, nine were managed surgically (of these, two had a prior PCD) and two patients were managed conservatively. The overall mortality was 9.5% (2/21). Thus, percutaneous management was suitable for 57% patients, was successful in 83.3%, with a mortality of 8.3%. Surgical therapy alone was offered to 33% of patients, was successful in 85.7%, with a mortality of 14.2%. Complications were seen in four of the nine patients managed by percutaneous drainage alone and eight of the nine patients managed surgically. Conclusions: Pancreatic abscess is a potentially lethal complication in patients recovering from acute pancreatitis. Early diagnosis and prompt intervention with careful selection of patients based on computed tomography imaging for surgical or percutaneous radio­logical management, is met with a successful outcome in a majority of patients. The roles of surgery and PCD are complementary.     

克隆病合并膀胱内瘘的诊治分析（附12例报告）

目的总结分析克隆病合并膀胱内瘘的临床特点和诊治策略。方法多单位联合回顾性统计12例克隆病（Crohn＇s disease,CD）合并膀胱内瘘的病例数据,包括年龄、性别、症状、治疗措施、手术情况、并发症、术后Α院时间及临床随访等情况,κ料来源于克隆病临床数据库。结果克隆病合并膀胱内瘘的症状以气尿为主（66.67%）,12例患者均有脓尿 全组病例中行I期受累肠段切除＋膀胱修补8例（66.67%） 10例术后平均随访24.28个月,无疾病复发。结论克隆病患者出现气尿为合并膀胱内瘘的主要临床证据 源器官切除＋靶器官修补的外科治疗方法预后良好。     

Pancreatic pseudocysts: 10 years of experience

BACKGROUND: Pancreatic pseudocysts (PP) are considered to be one of the major complications of acute, chronic, and posttraumatic pancreatitis. Their treatment has always been a surgical challenge. Surgical treatment was for many years the only choice in the management of PP. However, technological development has provided new alternatives in their management. PURPOSE: The purpose of this retrospective study is to present our experience in the treatment of PP and to define the criteria for the selection of the treatment method. METHODS: During the past decade, 14 patients were treated for PP in our clinic. We classified our patients in three groups based on the treatment: A, conservative treatment; B, surgical treatment with internal drainage; and C, percutaneous external drainage (PED) under CT guidance. RESULTS: Conservative treatment had excellent outcome when it was applied in patients with small cysts. Internal drainage was always successful, but patients needed more hospitalization and showed increased morbidity compared to PED. PED was successful in two of three patients. CONCLUSIONS: Conservative treatment is a good choice for small asymptomatic cysts, particularly for patients who are poor candidates for operation. Internal drainage is a good method of treatment and should be used as the first choice by experienced surgeons. Finally, PED is a good first choice for patients with a unilocular cyst and contraindications for surgery.