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PubMed2004

Endoscopic management of pancreatic fistula after pancreatic and other abdominal surgery.

Post-operative pancreatic fistulae represent a challenge for all the actors in gastroenterology: for surgeons, because they want to prevent and treat conservatively this complication since re-operation is associated with high morbidity and mortality rates; for radiologists, because they have to provide the best staging and informations without any additional risk; and for endoscopists, because endoluminal treatment is emerging as a safe and effective procedure provided it is performed in highly experienced tertiary centres in the setting of a multidisciplinary approach. Herein, we review the definitions, the causes, the staging and the possible options to prevent or treat post-operative pancreatic fistulae. Special attention is paid to the endoscopic management of this complication: including the relief of ductal obstructions, the stenting of leakages and the drainage of bulging or non-bulging fluid collections. Practical problems and issues are clearly outlined as well as the need for future improvements in staging and management of the patients having such complications.

Cholangiopancreatography, Magnetic Resonance↗
PubMed2006

Management of enterocutaneous fistulas using negative-pressure dressings.

Fifteen patients with enterocutaneous fistulas (ECFs) not amenable to surgical treatment were treated with negative-pressure dressings over the abdominal wound and ECF. Closure of the ECF and time to closure were examined. In 11 patients who had no visible intestinal mucosa on examination, the closure rate was 100%, with a mean time to closure of 14 days. In 4 patients who did have grossly visible intestinal mucosa, no closure occurred. This represents an overall closure rate of 73%. Fistula output rate did not have a significant effect on outcome. These results confirm the efficacy of negative-pressure dressings in the closure of ECFs. Presence or absence of visible intestinal mucosa is the single most important clinical factor when considering the use of a negative-pressure dressing in the management of a patient with ECF.

Adult↗
PubMed2002

[Secondary aorto-enteral fistula--material of 22 years and literature review].

INTRODUCTION: Aorto-enteral fistula is a pathological communication between the aorta and the bowel lumen. In its secondary form is a dreaded, often fatal complication of the aorto-iliac operations. METHODS: We report 34 secondary fistulas, a great number of patients treated in the last 22 years. One can rarely find such a number in the literature. RESULTS: The incidence of secondary fistulas is 0.42% following aorto-iliac operations. We give a detailed description of diagnostics. We prefer in situ solutions (graft change, aorto-aortic interposition, iliac desobliteration, homograft or deep venous bypass, aorto-bifemoral bypass) to extra-anatomical bypasses. We emphasize the importance of the postoperative care, and the necessity of adequate antibiotic therapy. CONCLUSION: Despite improved operations and intensive care mortality is still high (55.88%). We find that prevention is of great importance.

Aorta, Abdominal↗
PubMed2003

Foker's technique in oesophageal atresia with double fistula: a case report.

The authors' starting point is a new surgical approach described by Foker and performed by them on a newborn with long-gap oesophageal atresia. We discuss the possibility of obtaining rapid growth of the atretic oesophagus and performing a primary anastomosis in the case of long-gap oesophageal atresia. With this procedure, primary oesophageal repair could be performed without myotomies, without flaps and with the gastrooesophageal junction below the diaphragm. The need for gastrostomy would be also eliminated if the patient underwent the operation as a neonate.

Anastomosis, Surgical↗
PubMed1997

[Value of endoscopy in the treatment of chronic pancreatitis].

Endoscopic treatment in patients with chronic pancreatitis involves several features: sphincterotomy of the wirsung, dilatation, insertion of a prosthesis, cystoenterostomy, cystowirsungostomy. Extracorporal lithotrity is often associated. Endoscopic treatment appears to give satisfactory short-term results in cases with pain, pseudocyst or pancreatic fistula. Morbidity is low. The optimum duration of endoscopic drainage via the prosthesis is still a question of debate and the long-term efficacy remains to be demonstrated. Endoscopic treatment is indicated in patients with a definitive or temporary surgical risk or may be indicated for all symptomatic patients. In this case, endoscopic treatment would be used as a therapeutic test. Stenosis of the main bile duct is not at present a good indication for endoscopic treatment as this stenosis is resistant to balloon dilatation and prosthesis calibration.

Chronic Disease↗
PubMed1982

[Contribution of artificial feeding to the prevention of fistulae, anastomotic breakdowns, and eviscerations. Applications to diffuse postoperative peritonitis in eight cases (author's transl)].

Based on the study of 8 cases diffuse post-operative peritonitis, the authors demonstrate in an exemplary manner the benefit derived through artificial nutritive support which permits, in certain well-defined cases, one-step digestive sutures and allows high-quality anastomotic and parietal healing. This new therapeutic attitude should not be generalized; it remains as yet very special, requiring specific metabolic safety measures. Only surgical teams in total control of the metabolic and nutritive problems accompanying heavy visceral surgery are in a position to apply this new concept.

Adult↗
PubMed2004

Staged surgery for chronic primary aortoduodenal fistula in a septic patient.

Aortoenteric fistula is one of the most challenging problems that confront the vascular surgeons. Controversy remains over the optimal treatment because of the continued publication of series with high mortality, amputation, and aortic disruption rates. A positive preoperative blood culture is the best predictor of mortality with increased amputation rates due to infection of the extra-anatomic bypass. Therefore, in selected cases with sepsis, a prudent management protocol is required. We report a 68-yr-old male presenting with a chronic primary aortoduodenal fistula extensively involving the duodenum and Gram-negative sepsis. We planned a staged operation. Initially, an emergency laparotomy and control of the aorta allowed stabilization of the patient, identification of the fistula, and direct in situ placement of the prosthetic graft followed by an en bloc resection of the aneurysm and the surrounding structures. After he recovered from sepsis and had been stabilized, a staged extra-anatomic bypass followed by transabdominal removal of the temporarily placed graft was done. This management plan will allow the highest success rate and may be a prudent management protocol for these difficult cases.

Aged↗
PubMed2002

Rectovestibular fistula with absent distal vagina in an adolescent Nigerian girl.

Rectovestibular fistula is the most common variant of anorectal malformations reported in girls. Rarely does the whole of the anorectum occupy an ectopic position in the vestibule of the vulva. The authors report a case of a 15-year-old girl with rectovestibular fistula associated with occult distal vaginal atresia that was managed successfully by posterior sagittal anorecto-vaginoplasty (PSARVP).

Adolescent↗
PubMed2003

The fistulectome: a new device for treatment of complex anal fistulas by "Core-Out" fistulectomy.

PURPOSE: In an attempt to improve the quality of life of patients with high anal fistula, we developed a new mechanical device, a "fistulectome," which excises the fistula tract in a totally controlled manner, particularly useful in the treatment of high anal fistulas. The "fistulectomy set" consists of a flexible shaft, cannulation and fixation guides, an incisor mouth, and a handle, which is simultaneously used for motor housing. METHODS: The principle of the treatment is to excise approximately 2-mm thickness of the fistula tract circumferentially, which in fact is a "coring-out" procedure. The fistula tract is likewise transformed into a cylindrical cavity encircled by healthy tissue. This is achieved by the fistulectomy set, consisting of a flexible shaft, cannulation and fixation guides, an incisor mouth, and a handle simultaneously used for motor housing. RESULTS: Between March 2001 and April 2002, a total of 13 consecutive patients with anal fistula underwent excision of fistula tracts. All patients except one had previously been operated on for anal fistula. The distribution of fistulas was as follows: transsphincteric, six patients; suprasphincteric, three patients; extrasphincteric, three patients; multiple, one patient. Mean follow-up was 13.4 (range 7.5-18) months. Gas incontinence in one patient, soiling in one patient, and recurrence in one patient was observed. No recurrences, stool, or gas incontinence were observed in ten patients. CONCLUSIONS: Excision of fistula tract performed by the recently developed fistulectome is a minimally invasive, safe, and effective method to be considered in the treatment of anal fistula. The results obtained up to date were encouraging, although the patient number was limited.

Adult↗
PubMed1998

Rectal sleeve advancement: repair of rectovaginal fistula associated with anorectal stricture in Crohn's disease.

Successful repair of rectovaginal fistula in patients with Crohn's disease has been reported when these patients have a normal appearing rectum. We report the performance of stricturectomy in conjunction with circumferential rectal sleeve advancement for patients who have a rectovaginal fistula arising from an anorectal stricture secondary to Crohn's disease. This technique provides for repair of rectovaginal fistula and correction of the anal stricture and maintains continence.

Constriction, Pathologic↗
PubMed1978

Site of emetic action of oral copper sulfate in dogs. (I) Thresholds of various portions of gastrointestinal tract to locally applied copper sulfate.

Emetic thresholds to copper sulfate administered into the Pavlov pouch, Forrest pouch, Thiry fistulas of the jejunum and ileum, and duodenal, jejunal and ileal catheters were measured in dogs to conjecture the site of emetic action of copper sulfate. The oral emetic threshold had been measured preoperatively. In the stomach, the pyloric antrum had a high sensitivity, while the corpus had a low sensitivity to the topically applied copper sulfate. In the intestine, the sensitivity was high in the duodenum, whereas a low sensitivity was noted in the jejunum. Almost no sensitivity was observed in the ileum. Thus it would appear that the site of the emetic action of copper sulfate was the pyloric antrum and/or duodenum.

Administration, Oral↗
PubMed1983

Gastrointestinal disease: nutritional implications.

The management of patients with gastrointestinal disease must include attention to nutritional status. It has been documented that morbidity and mortality previously considered common in these patients can be reduced significantly. Perhaps the largest contribution that advances in nutritional support have made is the reduction in the frequency of surgical intervention. Remission of inflammatory bowel disease, closure of fistulas, intestinal adaptation, and prevention of malnutrition in complicated pancreatitis with the use of nutritional therapies help to avoid the complications of operative procedures.

Crohn Disease↗
PubMed2004

Endoscopic sealing of pancreatic fistula by using N-butyl-2-cyanoacrylate.

BACKGROUND: The treatment of pancreatic fistula can be difficult. A novel endoscopic approach to sealing pancreatic fistulas by using N-butyl-2-cyanoacrylate is described. METHODS: Twelve patients with pancreatic fistulas underwent endoscopic injection of N-butyl-2-cyanoacrylate into the fistulous tract, in addition to endoscopic drainage. RESULTS: Fistulas were closed successfully in 8 of 12 patients. A single treatment session was successful in 7 patients; a second session was required in one patient. In two patients, closure was temporary, and, in one patient, the treatment failed. One patient died 24 hours after treatment. He developed a pulmonary thromboembolism from a left popliteal vein thrombosis and died from complications of surgical thromboembolectomy. At autopsy, a pulmonary embolus was found, but there was no evidence of N-butyl-2-cyanoacrylate in the lungs. No procedure-related complication occurred over a median follow-up of 20.7 months (range 9-51 months). CONCLUSIONS: In this preliminary study, occlusion of pancreatic fistulas by using N-butyl-2-cyanoacrylate glue was safe and effective, and obviated the need for surgery in a substantial proportion of patients. Further studies of the use of N-butyl-2-cyanoacrylate for closure of pancreatic fistula are warranted.

Adult↗
PubMed1988

[Gastrointestinal interventional radiology. Technics and preliminary results].

Gastrointestinal interventional radiology allows the positioning of feeding tubes in difficult situations, as well as the balloon dilatation of stenoses and the transintestinal drainage of fistulas and collections, with some advantages over endoscopic and surgical procedures. In the present series feeding tubes were positioned in 26 patients, both to get over the strictures in the upper gastrointestinal tract and to exclude fistulous tracts or anastomotic leaks from alimentary transit. Balloon dilatation was performed in 10 patients with stenoses of different aetiologies, at different levels of the gastrointestinal tract: in all cases the clinical symptoms diminished. All the 7 non-neoplastic stenoses were successfully treated (follow-up 6-27 months). The draining of abscesses through the enteric fistulous tract did allow the reduction/resolution of all collections in a short time. These procedures are simple and safe, and help to reduce the interval between diagnosis and therapy. Their failure does not prevent the use of other therapeutic procedures.

Abscess↗
PubMed1998

Definitive repair of anovaginal fistula in Crohn's disease.

Anovaginal fistula may be a very distressing complication of Crohn's disease. We review the definitive repair of such fistulas in ten patients. The objectives were to cure the fistula, maintain continence and avoid proctectomy. The fistula was low trans-sphincteric in five patients, high trans-sphincteric in three and suprasphincteric in two. Loop ileostomies were formed in nine patients. Overall, after 14 repair procedures 8/10 fistulas are healed. Seven remain healed at a mean of 38 months (range 10-66 months) after ileostomy closure (six) or repair without ileostomy (one). All of the patients are continent. Definitive repair is effective and worthwhile in selected patients with Crohn's anovaginal fistula.

Adult↗
PubMed2005

A multidisciplinary approach to the treatment of intestinal failure.

Intestinal failure is most commonly treated by the administration of total parenteral nutrition (TPN). In some patients, however, surgical therapy may increase the ability to use the intestine for nutrition and thereby decrease the complications of TPN therapy. A multidisciplinary comprehensive intestinal failure program was initiated at the University of Nebraska Medical Center in October 2000. Here we describe the surgical approaches to patients with short bowel syndrome and the subsequent impact on the need for TPN and on survival. Fifty patients (children=30, adults=20) underwent surgical procedures to restore intestinal continuity (n=5), repair enterocutaneous fistulas (n=5), resect dysmotile or strictured/obstructed bowel segments or mesenteric desmoid tumors (n=7), stricturoplasty (n=2), Bianchi tapering and lengthening (n=20), serial transverse enteroplasty (n=8), and other operations (n=8). Of these 50 patients, three patients did not require TPN after surgical intervention and seven had remnant small bowel anatomy that precluded TPN weaning (e.g., end duodenostomy) and were listed for transplantation or continued on full TPN support. Of the 40 remaining patients, most received the majority of calories from TPN at the time of referral, i.e., mean calories from TPN=90%. Subsequent to the surgical and medical therapy, 26 (65%) have been completely weaned off TPN. In addition, 10 had substantial decreases in their TPN requirements (i.e., from 85% of calories from TPN at onset decreased to a median 35% of required calories at most recent follow-up). Four patients remained on the same amount of TPN support. Four of the seven patients listed for transplantation underwent successful transplantation. Despite the complications of short bowel syndrome, 86% (n=43) of the patients are alive and well at a mean follow-up of 2 years. Patient deaths occurred primarily in those listed or eligible for transplantation and were related to advanced liver disease (n=3), gastrointestinal hemorrhage (n=1), or line sepsis (n=1). Two other patients died, one from influenza A infection and one from unknown cause at home, months after complete discontinuation of TPN. In this series of patients with short bowel syndrome, surgical intervention led to weaning or discontinuation of TPN support in 85% of patients. An organized multidisciplinary approach to the patient with short bowel syndrome is recommended.

Adolescent↗