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At least 433 records · Page 24Linked to original sources
PubMed2007

Staging rectourinary fistulas to guide surgical treatment.

PURPOSE: Surgical management for rectourinary fistulas remains a reconstructive challenge. There are few guidelines to direct the surgeon to the most successful and least morbid technique. We developed a rectourinary fistula staging system that allows selection of the most appropriate technique for the patient. We present the details of the staging system and surgical outcomes. MATERIALS AND METHODS: From July 1999 to July 2005 we treated 14 male patients with rectourinary fistula. Mean patient age was 68 years (range 62 to 73). Etiology was rectal injury during open radical prostatectomy in 5 patients, laparoscopic prostatectomy in 1, radiation induced fistula for prostate cancer treatment (brachytherapy and external beam radiation therapy) in 2, neoadjuvant external beam radiation therapy in 2, ischial decubitus ulcer in 3 with spinal cord injury, and cryotherapy and external beam radiation therapy in 1. Cases were staged as stage I--low (less than 4 cm from anal verge and nonirradiated), stage II--high (more than 4 cm from anal verge and nonirradiated), stage III--small (less than 2 cm irradiated fistula), stage IV--large (more than 2 cm irradiated fistula) and stage V--large (ischial decubitus fistula). Diverting colostomy was performed for stages III to V 6 weeks before definitive therapy. RESULTS: Patients were discharged home after 48 hours. A 22Fr urethral catheter maintained bladder drainage for 3 weeks until cystogram confirmed rectourinary fistula closure. Complications were superficial wound infection and postoperative reexploration of the gracilis flap due to bleeding in 1 case each. All patients were cured after a single operation. CONCLUSIONS: The surgical challenges of a variety of rectourinary fistula repairs can be managed with minimal morbidity and a high success rate using proper staging to guide urinary tract reconstruction.

Aged↗
PubMed2002

Selective occlusion with fibrin glue under fistuloscopy: seven cases of postoperative management for intractable complex fistulas.

BACKGROUND AND STUDY AIM: Fistula occlusion is not achieved in some fistulas with complex branches. To obtain early fistula closure in such cases, we insert a double-lumen catheter into each fistula branch, with the aid of a guide wire positioned using a small-caliber endoscope, and attempt selective infusion of fibrin glue. PATIENTS AND METHODS: Following removal of foreign bodies and necrotic granulation, we applied the selective occlusion method under fistuloscopic control to seven intractable external fistulas with complex branches, in which fistula closure had not been obtained by a simple occlusion method (SOM). All the fistulas were complex with more than two branches. RESULTS: Fistula occlusion was obtained within 2 weeks in six of the seven patients, and there has been no sign of recurrence over a follow-up period of 4 - 59 months (average 29.8 months). CONCLUSION: Selective occlusion under fistuloscopy is highly effective for intractable external fistulas with complex branches.

Digestive System Surgical Procedures↗
PubMed2001

Advanced gallbladder carcinoma with biliobiliary fistula, resected by hepatopancreatoduodenectomy, in an aged patient.

We report a 78-year-old man with a gallbladder carcinoma and biliobiliary fistula, diagnosed by percutaneous transhepatic cholangioscopic biopsy through the fistula. The impacted stones in the common hepatic duct were crushed, and then selective cholangiography under percutaneous transhepatic cholangioscopy (PTCS) revealed a biliobiliary fistula. Cholangioscopic biopsy tissues taken from the gallbladder revealed adenocarcinoma, but biopsies taken from the fistula revealed no evidence of malignancy. Further investigations indicated that the gallbladder carcinoma involved the duodenum and the distal common bile duct. A hepatopancreatoduodenectomy, including both an extended right hepatic lobectomy with resection of the caudate lobe and a pancreatoduodenectomy, was performed. Despite the patient's advanced age, he made an unremarkable postoperative recovery and was able to enjoy an active social life for 8 months after the surgery. We discuss biliobiliary fistula associated with gallbladder carcinomas and the use of hepatopancreatoduodenectomy for advanced biliary cancer in aged patients.

Aged↗
PubMed1975

Lipid absorption in bile fistula rats. Lack of a requirement for biliary lecithin.

The role of biliary or dietary phosphatidylcholine (lecithin) in the process of lipid absorption was studied in bile fistual rats. Jejunal lipid-reesterifying enzyme activities were determined in experimental rats given diet, bile salts and phosphatidylethanolamine and results compared to controls given diet alone. Lipid absorption was also studied in vivo with radioactive techniques. Two groups of bile tistula rats were used. Both received diet and bile salts. In addition, one group was given phosphatidylethanolamine and the other received lecithin. Enzyme activities were moderately but significantly reduced in bile tistula rats receiving phosphatidylethanolamine. This was associated with an abnormal phospholipid composition of the microsomal membrane. Despite the changes in mucosal enzyme activity, however, no abnormality of lipid absorption was noted in bile fistula rats that received phosphatidylethanalamine. Results in this group were similar to controls and to the other bile fistula group given lecithin. In all groups, significant amounts of lecithin were recovered from the lumen of the small bowel. It is concluded that if lecithin is required for lipid absorption, it does not have to be supplied to the small bowel via the diet or in bile.

Acyltransferases↗
PubMed2002

Biliary drainage by endoscopic choledochoduodenal fistulotomy in patients with papillary carcinoma.

BACKGROUND: There are few reports of endoscopic choledochoduodenal fistulotomy (endoscopic fistulotomy) in patients with papillary carcinoma by using a needle-knife. METHODS: Among 35 patients with papillary carcinoma requiring biliary drainage, 14 with a suprapapillary bulge underwent endoscopic fistulotomy alone or with widening of the fistula by using a standard sphincterotome or dilation balloon catheter. OBSERVATIONS: Transfistula bile duct cannulation was successful on the first attempt in 13 of 14 patients (93%) and temporary biliary drainage through the fistula was successfully established in all 13 patients. The single complication was minor bleeding (7%) in 1 patient. In 6 patients with biliary obstruction who were not operative candidates, endoscopic fistulotomy was used for palliation, and all remained asymptomatic for a mean period of 3.2 months. CONCLUSIONS: Endoscopic fistulotomy is an effective, relatively safe biliary drainage procedure. It should be considered in selected patients with bile duct obstruction caused by papillary carcinoma and a suprapapillary bulge caused by the dilated bile duct.

Adult↗
PubMed2004

Salvage surgery after restorative proctocolectomy.

Restorative proctocolectomy is now the elective surgical procedure of choice for most patients with ulcerative colitis or familial adenomatous polyposis. There are four causes of failure including acute and chronic sepsis, poor function for mechanical or functional reasons, mucosal inflammation (including pouchitis and retained rectal mucosa) and neoplastic transformation. Failure rates themselves range from 5% to nearly 20%. Followed over a period of 20 years, the failure rate can be summarised approximately as 5% at five years, 10% at ten years and 15% at 15 years.

Digestive System Surgical Procedures↗
PubMed2006

Infliximab in fistulizing Crohn's disease.

The treatment of fistulizing CD has evolved greatly in the last 15 years, largely caused by improvements in medical therapy. Tables 2 and 3 summarize all published controlled and uncontrolled trials of immunomodulator and biologic therapy for the treatment of Crohn's fistulae. The advent of immunomodulators and anti-TNF-alpha agents has transformed the treatment of Crohn's fistulae from almost exclusively surgical to placing a much larger emphasis on medical therapy, either as initial therapy alone, with surgery reserved for refractory cases, or in combination with surgery from the start. For this reason, surgeons and gastroenterologists must work in concert to provide the best care for each patient. Proper fistula management also relies heavily on accurate diagnosis, especially defining the anatomy of the fistula, ascertaining whether abscess formation is present, and determining the location and extent of intestinal inflammation.

Anti-Inflammatory Agents↗
PubMed2002

Surgical methods for anorectal malformations from Rehbein to Peña--critical assessment of score systems and proposal for a new classification.

In this review article the surgical techniques of Rehbein, Romualdi, Kiesewetter, and Peña/De Vries are compared and corresponding surgical steps are pointed out. Peña/De Vries have adopted many surgical steps from Stephens and further standardized this technique. The results of recent postoperative examinations are presented with regard to the surgical methods of Stephens, Rehbein, Romualdi, Kiesewetter, and Peña. In that connection, the paper makes it clear that comparison of postoperative studies is not possible because the authors evaluate too small numbers of cases, use different scoring systems, do not indicate individual steps of their surgical techniques and do not consider the height of the atresias. The reference to the type of fistula that can be found in recent literature unfortunately does not provide a common basis for comparative studies either. Therefore, the paper suggests complete abandonment of scoring systems and classification of postoperative continence results instead according to the therapy that has to be applied. In addition, it again stresses the importance and necessity of adhering to the Wingspread classification.

Anal Canal↗
PubMed2003

[Perineal canal].

The malformation, perineal canal, is a rare condition accounting for the 4% of all anorectal malformations. We report a 15 months old female that presented passage of feces per vagina during a diarrheal disease. Former physical exam did not show any fistulous opening, another exam under sedation and radiological study with barium leaded to the diagnose of perineal canal. The fistula was excised without preceding colostomy. After surgery the patient did well without complications. Several diagnostic techniques and surgical approaches are analyzed. The authors believe that the surgical procedure used in this patient have had good outcome and the advantage of no needing of preceding colostomy.

Digestive System Surgical Procedures↗
PubMed2002

Simultaneous anus and bowel operation is preferable for anal fistula in Crohn's disease.

BACKGROUND: Anal fistula in Crohn's disease is reportedly intractable, and little is known about factors influencing the outcome of surgery. The purpose of this study was to clarify the current status of surgery for anal fistula in Crohn's disease, and possible factors influencing surgical outcome were investigated. METHODS: From August 1993 to September 1998, 39 of 239 Crohn's disease patients underwent long-term seton drainage. The patients were divided into two groups: patients who received simultaneous bowel and anus operation (simultaneous group; n = 11) and a control group ( n = 28). RESULTS: Twenty-nine of the 39 (74%) patients received two seton drains or more, with a mean of 2.7. Twenty-one (54%) patients received two or more operations. The rate of seton drain removal was 52% at 12 months after operation and 86% at 24 months. The cumulative rate of seton drains remaining at 12 months after the first operation was 10% in the simultaneous group and 37.7% in the control group, with a significant difference ( P = 0.038). Multivariate analysis revealed that simultaneous operation was the only significant factor that influenced the surgical results ( P = 0.0489). Seven of the 21 (33%) patients recurred after total removal of seton drain(s). All the patients who had recurrence belonged to the control group. Continence did not deteriorate after seton drainage. Ten patients (26%) required enterostomy and no patient received proctectomy. CONCLUSIONS: Healing of Crohn's anal fistula was significantly better in the simultaneous group than in the control group, and the recurrence rate was lower in the simultaneous group. Seton drainage for anal fistula in Crohn's disease was effective and preserved sphincter function.

Crohn Disease↗
PubMed2004

The posterior sagittal trans-sphincteric approach.

The posterior sagittal, transphincteric approach to treat different pelvic problems has been known since last century. Although some surgeons have embraced it and have enthusiastically advocated it s use, it has never become an overly popular technique. The purpose of this study is to evaluate the advantages and disadvantages of the approach, both from an historical perspective and from the authors experience. The international literature on the subject was reviewed since 1877 up to the present date. A retrospective evaluation of the authors experience was conducted, and the results reviewed. Specific attention was paid to the final result obtained in the treatment of the original condition, surgical complications and the effect of the surgical approach on bowel and urinary control. The experiential review included 114 cases. They were divided into two groups. A included 85 patients who underwent a posterior sagittal transphincteric approach that included 49 cases of Hirschsprung s disease (primary 21, secondary 28), 15 presacral masses; 10 rectaltumors; 7 acquired recto-genito-urinary fistulae; and 4 cases of idiopathic rectal prolapse. Group B included 29 patients who underwent a posterior sagittal trans-anorectal approach, in which the anterior wall of the rectum and the sphincter was divided as well.. This group included 12 cases of urogenital sinuses; 8 acquired urethral stricture or atresia after trauma; and 9 posterior urethral masses. Post-operative bowel control was normal all cases except in those patients whose basic condition had resulted in fecal incontinence, or who had sustained an irreversible injury prior tothe operation. Urinary control was normal except in cases with pre-operative incontinence. Complications included recurrence of recto-genitourinary fistulae in 3 cases, recto-cutaneous fistula in 3 Hirschsprung s patients and 2 partial wound dehisences. The posterior sagittal trans-sphincteric approach represents a useful technical alternative. It seems to be particularly useful to treat complications after surgery for Hirschsprung s disease, pre-sacral masses, acquired recto-genito-urinary fistula and idiopathic rectal prolapse. The transanorectal approach provides excellent exposure to the posterior urethra and vagina. Boweland urinary control are not compromised.

Adolescent↗