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PubMed1999

Preoperative enzymo-histochemical diagnosis of dysganglionoses associated with anorectal malformations (ARM) with recto-vestibular and recto-perineal fistula.

The posterior sagittal anorectoplasty (PSARP) is widely recognized as the best technique available today for the surgical treatment of anorectal malformations (ARM). However, different retrospective studies on the functional results of PSARP in the treatment of ARM have shown different postoperative degrees of constipation. In particular, even in patients with normal sacrum, about 70% of operated ARM with vestibular fistula and about 50% with perineal fistula can be complicated by fecal constipation and pseudoincontinence. In order to identify preoperatively whether ARM patients present abnormal innervation patterns of rectal pouch and fistula (as reported by Holschneider et al [7]), we decided to study suction rectal biopsies performed by introducing SBT-100 rectal suction biopsy tool into the fistula at 6, 4, 3 and 2 cm from the meatus. To date, this approach has been adopted in 22 ARM cases (15 females and 7 males, age range 7 days-4 years), 6 of them with recto-vestibular fistula and 13 with recto-perineal fistula. Biopsies were frozen in isopentane at liquid nitrogen temperature and cryostatic sections were studied by acetylcholinesterase (AChE), succinic-dehydrogenase (SDH) and alpha-naphthyl-esterase (ANE) enzymo-histochemical techniques. The results concerning the innervation-type of fistula and proximal rectal pouch were confirmed by the biopsies obtained during PSARP. Our overall incidence of rectal innervation intrinsic disorders was 81.82%. In particular, all our cases of vestibular fistula presented associated dysganglionoses. The incidence of associated Hirschsprung's disease was high, corresponding to 18% of cases. Our results suggest that the high frequency of constipation in low forms of ARMS depends on primary intestinal neuronal malformations and it cannot be ascribed to a denervation secondary to rectal dissection and to PSARP procedure. We propose the introduction of this type of preoperative enzymo-histochemical diagnosis in ARM cases because it can select those patients with severe associated dysganglionoses. In our opinion, if this diagnosis is available preoperatively, PSARP can be performed without using abnormally innervated structures and reducing postoperative functional complications.

Anal Canal↗
PubMed2005

Entero-enteric fistula following mild necrotizing enterocolitis.

We report a 26-week gestational age newborn who developed an entero-enteric fistula associated with a small bowel stricture following a mild episode of necrotizing enterocolitis. The fistula led to a delay in the diagnosis and surgical treatment of the stricture, and should therefore be considered in the setting of partial or intermittent obstruction in the newborn who has had necrotizing enterocolitis.

Constriction, Pathologic↗
PubMed1999

Malrotation in conjunction with esophageal atresia/tracheo-esophageal fistula.

Esophageal atresia or tracheo-esophageal fistula (EA/TEF) often occurs in association with a well-defined group of other anomalies. We report the prevalence of malrotation and other intestinal anomalies in a large data series comprising 632 nontrisomic infants with EA/TEF ascertained by the California Birth Defects Monitoring Program from January 1, 1983 to December 31, 1994. Consistent with findings reported previously in smaller case series, our findings showed a notable prevalence of imperforate anus (9.0%) and duodenal atresia (5.2%), among other gastrointestinal defects. They also showed a previously unrecognized high prevalence of intestinal malrotation (4.4%). Compared with other infants studied, the infants with EA/TEF and malrotation of the intestine had a higher proportion of other associated anomalies (in particular intestinal, central nervous system, vertebral and rib, renal and genital anomalies). These findings indicate that intestinal malrotation is more common in infants with EA/TEF than is generally perceived, and that intestinal malrotation in an infant with EA/TEF is associated with a higher burden of additional congenital anomalies, suggesting that this group of infants may have more pervasive developmental deficits and poorer prognosis than has previously been recognized.

Digestive System Abnormalities↗
PubMed2001

Abdominosacral repair for a rectovaginal fistula with anastomotic stenosis after low anterior resection report of a case.

The management of a postoperative rectovaginal fistula after low anterior resection for rectal cancer is difficult and requires reconstruction of the anastomotic site and fistula. The results of reconstructive operation are often unsatisfactory. Herein, we describe our reconstruction technique using the posterior approach through the vaginal lumen for a high rectovaginal fistula repair. This reconstructive operation is useful for postoperative rectovaginal fistulas accompanied by severe stenosis of the anastomotic site following low anterior resection for rectal cancer.

Aged↗
PubMed2000

Diagnostic and therapeutic fistuloscopy: an adjuvant management in postoperative fistulas and abscesses after upper gastrointestinal surgery.

BACKGROUND AND STUDY AIMS: Postoperative fistulas and abscesses pose difficult management problems. We report our experience in the use of fistuloscopy in postoperative fistulas and abscesses after upper gastrointestinal surgery. PATIENTS AND METHODS: From June 1993 to January 1997, nine patients (seven men, two women; mean age 65) with postoperative fistulas and abscesses were treated with therapeutic fistuloscopy. Diagnostic fistuloscopy was carried out using a 5-mm choledochoscope under fluoroscopic guidance. Therapeutic procedures included mechanical debridement, irrigation, and sealing of fistula with fibrin sealant and gelatin sponge. RESULTS: The patients were suffering from duodenal stump fistula (three cases), gastrojejunostomy dehiscence after gastrectomy (three cases), gastropleurocutaneous fistula (two cases), and subphrenic abscesses (two cases). Fistuloscopy was performed 4-19 days (mean 12 days) after the diagnosis of the fistula. The median number of sessions required was 2 (range 1-4). The average daily fistula output prior to fistuloscopy was 154 ml (range 30-560 ml), and all fistulas healed in an average of 18.7 days (range 2-46 days) after index fistuloscopy. No procedure-related complications occurred. The mean hospital stay was 61 days. During a mean follow-up period of 12 months, no recurrent abscesses or fistulas developed. CONCLUSIONS: Fistuloscopy provides a new means of managing patients with postoperative fistula and abscess formation.

Abscess↗
PubMed2000

Effect of fecal diversion alone on perianal Crohn's disease.

The role of fecal diversion alone for perianal Crohn's disease remains unclear. This study was undertaken to assess its role in perianal Crohn's disease and to examine predictive factors for outcome. Thirty-one patients who underwent fecal diversion alone for perianal Crohn's disease between 1970 and 1997 were reviewed. The principal indications for fecal diversion were severe perianal sepsis in 13 patients, recurrent deep anal ulcer in 3, complex anorectal fistula in 9, and rectovaginal fistula in 6. Twenty-five patients (81%) went into early remission, and six (19%) failed to respond. Of the 25 early responders, 17 relapsed at a median duration of 23 months after fecal diversion. By contrast, 8 patients (26%) went into complete remission and required no further surgery at a median duration of 81 months after the diversion. Altogether, 22 patients required surgery at a median duration of 20 months after fecal diversion: proctectomy in 21 and repeated drainage of anal sepsis in 1. At present, intestinal continuity has been restored in only three patients (10%). The following parameters were compared in patients with and without complete remission after fecal diversion: age, gender, duration of disease, steroid use, smoking, coexisting Crohn's disease, preoperative blood indices, and Crohn's disease activity index. None of these parameters affected the outcome. In conclusion, fecal diversion alone is effective in selected patients with perianal disease, but the prospect of restoring intestinal continuity is low. There were no parameters to identify those in whom a successful outcome is likely.

Adolescent↗
PubMed2000

Sonographic diagnosis of a small fistulous communication between a subphrenic abscess and a perforated duodenal ulcer.

We report a case of a fistula between a subphrenic abscess and a perforated duodenal ulcer diagnosed by sonography and confirmed by CT. The sonographic findings included a subphrenic fluid collection connected to the anterior aspect of the superior duodenum by a nonpulsatile, anechoic tubular lesion. Manual compression of the upper epigastrium resulted in movement of echogenic debris from the antrum and superior duodenum through the fistulous tract into the abscess.

Aged↗
PubMed2002

Change in anal continence after surgery for intersphincteral anal fistula: a functional and manometric study.

BACKGROUND AND AIMS: Dividing or "laying open" of the tract for intersphincteral type anal fistula is simple and effective and entails low risk of complication, but little is known of the functional and manometric results. This study assessed the clinical and manometric effect of this surgery on anal sphincter function. PATIENTS AND METHODS: The study examined 45 adults undergoing surgical treatment for intersphincteral fistula. We administered the questionnaire for continence score and performed anorectal manometry before the operation and at least 6 months after the operation. The operative method was laying open of the fistula tract and trimming the redundant anoderm for adequate drainage of the wound in all cases. RESULTS: There was a significant decrease in maximal resting anal pressure and in resting pressure throughout the distal 2 cm of the anal canal after operation. The maximal contractile pressure after operation was similar to that before operation. Continence control was significantly poorer in women and patients who had lower preoperative resting pressure. Multivariate analysis showed lower preoperative resting pressure to be the only independent factor for impaired continence control after fistula surgery. CONCLUSION: Although laying open of the fistula tract is a simple and effective therapy for intersphincteral type anal fistula, it should be more conservative for patients with low resting anal pressure.

Adult↗
PubMed2006

[Results of combined surgeries for cancer of the colon complicated with stomach and duodenal fistulas].

Positive results of combined surgeries in locally advanced cancer of the colon complicated with gastric fistula (3 patients) and duodenal fistula (1 patient) are presented. Effective treatment of these patients requires complex examination, good preoperative preparation, perfect anesthetic management, adequate operation and intensive postoperative (including antibacterial) therapy.

Adult↗
PubMed2006

Simple clinical examination predicts complexity of perianal fistula.

OBJECTIVE: To investigate the diagnostic value of the distance between external opening of perianal fistula and anal verge and to evaluate its relation to the type of fistula. Preoperative identification of complex fistulae is important for proper planning of treatment. PATIENTS AND METHODS: One hundred and fifteen consecutive patients operated for perianal fistula were studied prospectively. The distance between the external opening and the anal verge was measured. Location of the external opening, demographic and medical history data were correlated with characteristics of the fistulae. Data analysis was performed using the SPSS statistical package. The association between categorical variables was examined using the chi(2)-test or Fisher's exact test for small sample. Comparison of continuous variables between two groups was analysed by t-test. RESULTS: The mean distance between external opening and anal verge in simple fistulae was 2.8 cm (range 1.5-4.3, SD 0.689) and in complex fistulae it was 4.4 cm (range 3.5-6.0, SD 0.526). This difference was statistically significant -P < 0.0001. Age and previous operations (particularly attempted definitive operations) were also significantly related to the complexity of the fistula. Data concerning location and direction of the fistulous tracts confirm the validity of Goodsall's rule. CONCLUSION: Simple preoperative clinical examination may reliably predict the complexity of a perianal fistula. Identification of these patients permits to select the cases that should have specific sophisticated preoperative work-up. The first definitive operation is most important to assure a successful outcome, thus such preoperative triage may also permit selective referral to a specialized colorectal team.

Adolescent↗
PubMed2002

In situ vs ex situ pancreatic duct stents of duct-to-mucosa pancreaticojejunostomy after pancreaticoduodenectomy with billroth I-type reconstruction.

BACKGROUND: Pancreatic fistula is a leading cause of morbidity and mortality after pancreaticoduodenectomy, and an external stent of pancreaticojejunostomy has been recommended to prevent pancreatic fistula. HYPOTHESIS: Duct-to-mucosa pancreaticojejunostomy should not require placement of an external stent. DESIGN: Nonrandomized control study. SETTING: University hospital. PATIENTS: Seventy-four patients undergoing pancreaticoduodenectomy with duct-to-mucosa pancreaticojejunostomy were allocated to either the ex situ group (external pancreatic stent drainage) or the in situ group (no external drainage). MAIN OUTCOME MEASURES: Operative mortality; postoperative complications, particularly pancreatic fistula; and patency of duct-to-mucosa pancreaticojejunostomy. RESULTS: Preoperative factors, indicated disorders, and intraoperative factors were similar for both groups. Mortality rates were 1% (1/74) overall, 3% (1 death) for the in situ group, and 0% for the ex situ group. Morbidity rates were 32% (12/37) for the in situ group and 35% (13/37) for the ex situ group. The incidence of pancreatic fistula was 5.4% and was the same for the in situ and ex situ groups. The incidence of delayed gastric emptying was similar for the in situ (19% [7/37]) and ex situ (14% [5/37]) groups. Ampullary tumors and pancreatic ducts 2 mm or less in diameter had a higher incidence of pancreatic fistula, but the incidence was similar in both treatment groups. Nasogastric tube drainage day, the median hospital stay, and pancreaticojejunostomy patency were similar in both groups. CONCLUSIONS: The results were considered to show equivalent outcomes for ex situ and in situ pancreatic stenting of the duct-to-mucosa pancreaticojejunostomy after pancreaticoduodenectomy. The use of transanastomotic stents has to be selective according to the individual characteristics of each patient. We recommend their use with ampullary tumors or small ducts (< or =2 mm).

Aged↗
PubMed1975

Congenital defects of the gastrointestinal tract and abdominal wall. A three-year review.

One hundred forty-four infants with anomalies of the gastrointestinal tract and abdominal wall were treated at Children's Memorial Hospital between July 1970 and July 1973. The overall mortality, including unoperated infants and those dying from other causes up to six months later, was 17%. Associated defects, particularly of the heart and CNS, were the most common causes for death. Many infants were premature; however, this factor alone did not contribute to mortality. Differences in surgical technique did not affect mortality in patients with esophageal atresia, but one baby with total aganglionosis of his colon and two with gastroschisis may have survived with different modes of therapy. Although previous advances in pediatric surgery contributed to the overall good results in these infants, parenteral alimentation emerged as the single most important factor in improved survival during this study period.

Abdominal Muscles↗
PubMedDate not supplied

Chevalier Jackson lecture. Respiratory and alimentary relations in staged human embryos. New embryological data and congenital anomalies.

The early development of the digestive and respiratory systems is summarized in relation to embryonic staging. It has frequently been emphasized that the digestive and respiratory tubes do not arise from a common chamber, that they pursue separate courses as soon as the lung bud appears, that a mesenchymal septum comes to intervene between them, and that the two tubes rapidly acquire independent outer coats. Some commonly held views such as the supposed caudorostral separation of the trachea from the esophagus, have been shown to be incorrect. These ideas often arose from the use of unstable landmarks during development. It is pointed out that, for 3 weeks after its appearance, the tracheoesophageal separation point remains at a constant level, whereas the tracheal bifurcation descends. The application of valid embryological data to the interpretation of several congenital anomalies has been shown to be of value. Although the modes of origin in some instances are still obscure, considerable advance has been made in understanding the timing of the relevant events.

Congenital Abnormalities↗
PubMedDate not supplied

[Anterior resection of the rectum for rectal cancer--options, limits, immediate complications].

A number of factors have recently led to a more conservative approach for middle or low rectal cancers, making possible sphincter preservation and reducing the number of abdomino perineal excisions of the rectum. We have performed a retrospective analysis on 510 patients operated on in our unit between 1994 and 2003 for rectal cancer. There were a number of 118 anterior resection of rectum; in 20 cases the TME has been performed and in 6 cases a very low anterior resection of rectum was done. The overall operative morbidity rate was 16.10% in direct relation with the distal limit of resection. We note urinary dysfunctions, anastomotic leakage, recto-vaginal fistulas as immediate postoperative complications. With the practice of total mesorectal excision, the use of abdomino perineal excision of the rectum is decreasing. The use of preoperative radiotherapy can increase the rate of operative morbidity but despite of these, its long-term benefit, is important.

Adenocarcinoma↗