Prevalence, diagnosis, and surgical management of complex ileocolic-duodenal fistulas in Crohn's disease.

BACKGROUND: The aim of the present study was to review the prevalence and surgical management of patients with Crohn's disease (CD) complicated by ileocolic-duodenal fistulas (ICDF). METHODS: We performed a retrospective chart review of CD patients who underwent surgical takedown and repair of ICDF during January 2011-December 2021 at two inflammatory bowel disease referral centers. RESULTS: We identified 17 patients with ICDF (1.3%) out of 1283 CD patients who underwent abdominal surgery. Median age was 42 (20-71) years, 13 patients were male (76%) and median body mass index was 22.7 (18.4-30.3) kg/m2. Four patients (24%) were diagnosed preoperatively and only 2 (12%) were operated on for ICDF-related symptoms. The most common procedure was ileocolic resection (13 patients, 76%) including 4 repeat ileocolic resections (24%). The duodenal defect was primarily repaired in all patients with no re-fistulization or duodenal stenosis, regardless of the repair technique. A laparoscopic approach was attempted in the majority of patients (14 patients, 82%); however, only 5 (30%) were laparoscopically completed. The overall postoperative complication rate was 65% including major complications in 3 patients (18%) and 2 patients (12%) who required surgical re-intervention for abdominal wall dehiscence and postoperative bleeding. Preoperative nutritional optimization was performed in 9 patients (53%) due to malnutrition. These patients had significantly less intra-operative blood loss (485 vs 183 ml, p = 0.05), and a significantly reduced length of stay (18 vs 8 days, p = 0.05). CONCLUSION: ICDF is a rare manifestation of CD which may go unrecognized despite the implementation of a comprehensive preoperative evaluation. Although laparoscopic management of ICDF may be technically feasible, it is associated with a high conversion rate. Preoperative nutritional optimization may be beneficial in improving surgical outcomes in this select group of patients.

The Role of Autologous Flap Reconstruction in Patients with Crohn's Disease Undergoing Abdominoperineal Resection.

BACKGROUND: Patients with symptomatic Crohn's disease who undergo abdominoperineal resection can experience impaired postoperative wound healing. This results in significant morbidity, burdensome dressing changes, and increased postoperative pain. When abdominoperineal resection is performed for oncological reasons, autologous flap reconstruction is occasionally performed to optimize wound healing and reconstruction outcomes. However, the role of flap reconstruction after abdominoperineal resection for Crohn's disease has not been established. OBJECTIVE: This study examines the utility of flap reconstruction in patients with symptomatic Crohn's disease undergoing abdominoperineal resection. We hypothesize that patients with immediate flap reconstruction after abdominoperineal resection will demonstrate improved wound healing. DESIGN: This study is a retrospective chart review. SETTINGS: Eligible patients at our institution were identified from 2010 to 2018 by using a combination of Current Procedural Terminology, International Classification of Diseases, Ninth Revision, and International Classification of Diseases, Tenth Revision codes. PATIENTS: Of 40 adult patients diagnosed with Crohn's disease, 20 underwent abdominoperineal resection only and 20 underwent abdominoperineal resection with flap reconstruction. INTERVENTIONS: Immediate autologous flap reconstruction was performed after abdominoperineal resection. MAIN OUTCOME MEASURES: The primary outcomes measured were the presence of postoperative perineal wounds and postoperative wound care burden. RESULTS: Patients in the abdominoperineal resection with flap reconstruction group demonstrated significantly worse preoperative disease traits, including fistula burden, than patients in the abdominoperineal resection only group. A lower number of patients tended to be associated with a persistent perineal wound in the flap group at 30 days (abdominoperineal resection with flap reconstruction = 55% vs abdominoperineal resection only = 70%; p = 0.327) and at 6 months (abdominoperineal resection with flap reconstruction = 25% vs abdominoperineal resection only = 40%; p = 0.311) postoperatively. There was also a trend toward a lower incidence of complications in the flap group. Patients in the abdominoperineal resection with flap reconstruction group tended to experience lower postoperative pain than patients in the abdominoperineal resection only group. LIMITATIONS: This retrospective cohort study was limited by its reliance on data in electronic medical records, and by its small sample size and the fact that it was a single-institution study. CONCLUSIONS: In select patients who have severe perianal fistulizing Crohn's disease, there may be a benefit to immediate flap reconstruction after abdominoperineal resection to lower postoperative wound care burden without significant intraoperative or postoperative risk. In addition, flap reconstruction may lead to lower postoperative pain. See Video Abstract at http://links.lww.com/DCR/B416. EL ROL DE LA RECONSTRUCCIN CON COLGAJO AUTLOGO EN PACIENTES CON ENFERMEDAD DE CROHN SOMETIDOS A RESECCIN ABDOMINOPERINEAL: ANTECEDENTES:Los pacientes con enfermedad de Crohn sintomática que se someten a una resección abdominoperineal pueden experimentar una curación posoperatoria deficiente de la herida. Esto da como resultado una morbilidad significativa, cambios de apósito molestos y un aumento del dolor posoperatorio. Cuando se realiza una resección abdominoperineal por razones oncológicas, ocasionalmente se realiza una reconstrucción con colgajo autólogo para optimizar los resultados de la curación y reconstrucción de la herida. Sin embargo, no se ha establecido la función de la reconstrucción con colgajo después de la resección abdominoperineal para la enfermedad de Crohn.OBJETIVO:Este estudio examina la utilidad de la reconstrucción con colgajo en pacientes con enfermedad de Crohn sintomática sometidos a resección abdominoperineal. Presumimos que los pacientes con reconstrucción inmediata con colgajo después de la resección abdominoperineal demostrarán una mejor curación de la herida.DISEÑO:Revisión retrospectiva de expedientes.MARCO:Los pacientes elegibles en nuestra institución se identificaron entre 2010 y 2018 mediante una combinación de los códigos de Terminología actual de procedimientos, Clasificación internacional de enfermedades 9 y Clasificación internacional de enfermedades 10.PACIENTES:Cuarenta pacientes adultos diagnosticados con enfermedad de Crohn que se someten a resección abdominoperineal solamente (APR-solo = 20) y resección abdominoperineal con reconstrucción con colgajo (APR-colgajo = 20).INTERVENCIÓN (ES):Reconstrucción inmediata con colgajo autólogo después de la resección abdominoperineal.MEDIDAS DE RESULTADOS PRINCIPALES:Presencia de herida perineal posoperatoria y carga de cuidado de la herida posoperatoria.RESULTADOS:Los pacientes del grupo APR-colgajo demostraron rasgos de enfermedad preoperatoria significativamente peores, incluida la carga de la fístula, en comparación con los pacientes del grupo APR-solo. Un número menor de pacientes tendió a asociarse con una herida perineal persistente en el grupo de colgajo a los 30 días (APR-colgajo = 55% vs APR-solo = 70%; p = 0.327) y 6 meses (APR-colgajo = 25% vs APR-solo = 40%; p = 0.311) postoperatoriamente. También hubo una tendencia hacia una menor incidencia de complicaciones en el grupo APR-colgajo. Los pacientes del grupo APR-colgajo tendieron a experimentar menos dolor posoperatorio en comparación con el grupo APR-solo.LIMITACIONES:Estudio de cohorte retrospectivo basado en datos de historias clínicas electrónicas. Tamaño de muestra pequeño y estudio de una sola institución.CONCLUSIONES:En pacientes seleccionados que tienen enfermedad de Crohn fistulizante perianal grave, la reconstrucción inmediata del colgajo después de la resección abdominoperineal puede beneficiar a reducir la carga posoperatoria del cuidado de la herida sin riesgo intraoperatorio o posoperatorio significativo. Además, la reconstrucción con colgajo puede resultar un dolor posoperatorio menor. Consulte Video Resumen en http://links.lww.com/DCR/B416.

Enterocutaneous fistula in patients with peritoneal malignancy following cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: Incidence, management and outcomes.

BACKGROUND: Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) is an effective treatment for peritoneal carcinomatosis (PC) from multiple origins, however is associated with increased complications compared to conventional gastrointestinal surgery. The aetiology of enterocutaneous fistulas (ECF) in most cases is a result of various contributing factors and therefore remains a major clinical problem, occurring in 4-34% of patients post-CRS. The aim of this study was to analyze the incidence and outcome of ECF following CRS/HIPEC. METHOD: From April 1999 to September 2015, 53 patients of 918 CRS/HIPEC procedures developed an ECF. Patient, operative and postoperative data were retrospectively analyzed to determine aetiology, classification outcome and possible contributing factors were reviewed on univariate and multivariate analysis. RESULTS: We report a 5.8% ECF rate, diagnosed at a median of 13 days. The mortality rate was 5.7% and other morbidity was significantly increased (p = 0.0001). Twenty-five (47.2%), 8 (15.1%) and 20 patients (37.7%) had low, moderate and high output ECF respectively. Patients that had a CC2 cytoreduction, abdominal VAC or smoked had a higher risk of fistula (p = 0.004, p < 0.0001, p = 0.008). Spontaneous closure was achieved in 49.2% with conservative treatment (median 29 days) and 33.9% underwent surgical intervention. Preoperative serum albumin <35 g/L (p = 0.04), PCI>17 (p = 0.025) and operation >8.6 h s (p = 0.001) were independent risk factors on multivariate analysis. Overall and 5-year survival was significantly reduced (p < 0.0001,p = 0.016). CONCLUSION: CRS/HIPEC remains an effective treatment modality for PC in selected patients with a comparable ECF incidence to reported elective gastrointestinal surgery rates. This study identifies multiple risk factors that should be considered in patients undergoing CRS/HIPEC.

Clinical Significance of Post-Operative Hyperglycemia in Nondiabetic Patients Undergoing Definitive Surgery for Gastrointestinal Fistula.

BACKGROUND: To evaluate the association between peri-operative hyperglycemia and adverse events in patients with gastrointestinal (GI) fistulas without a pre-operative diagnosis of diabetes mellitus who were undergoing definitive surgery. METHODS: Pre-operative and all post-operative blood glucose concentrations (BG) were retrieved for 363 consecutive patients undergoing GI reconstruction from September 2012 to December 2015. Normoglycemic (BG <125 mL/dL), mild hyperglycemia (125-199 mL/dL), and severe hyperglycemia (≥200 mL/dL) were defined using the highest BG found within the first 48 h post-operatively. Outcomes of interest included 30-d mortality rate and re-operation, time of enteral nutrition resumption, and infectious and non-infectious complications. RESULTS: More than half of the nondiabetic patients (61.4%) experienced hyperglycemia post-operatively. The degree of hyperglycemia correlated with patient age, American Society of Anesthesiologists class, and surgical interventions. Hyperglycemia was associated with re-operation and post-operative complications, the frequency of these complications increasing in parallel with the degree of hyperglycemia. Additionally, post-operative hyperglycemia was associated independently with surgical site infections (p = 0.014), anastomotic leak (p = 0.010), delayed resumption of enteral nutrition (p < 0.001), and longer hospital stay (p < 0.001). CONCLUSION: Elevated post-operative BG was frequent after surgery in patients with GI fistulas. Post-operative hyperglycemia is significantly associated with unfavorable outcomes, and this risk is related to the degree of BG elevation. Our findings suggest that vigilant post-operative BG monitoring and early appropriate glycemic control are critical for patients, even nondiabetic patients, undergoing definitive surgery for GI fistula.

Effect of insurance status on patients admitted for acute diverticulitis.

AIM: The study aimed to evaluate the relationship between insurance status and the management and outcome of acute diverticulitis in a nationally representative sample. METHOD: A retrospective cohort analysis of a nationally representative sample of 1 031 665 hospital discharges of patients admitted for acute diverticulitis in the 2006-2009 Nationwide Inpatient Sample (NIS), Healthcare Cost and Utilization Project data set. The main outcome measures included state at presentation (complicated/uncomplicated), management (medical/surgical), time to surgical intervention, type of operation and inpatient death. RESULTS: In total, 207 838 discharges were identified (including 37.0% with private insurance, 49.3% in Medicare, 5.6% in Medicaid and 5.8% uninsured) representing 1 031 665 total discharges nationally. Medicare patients were more likely to present with complicated diverticulitis compared with private insurance patients (23.8% vs 15.1%). Time to surgical intervention differed by insurance status. After adjusting for patient, hospital and treatment factors, Medicare patients were less likely than those with private insurance to undergo a procedure (Medicare OR = 0.86, 95% CI: 0.82-0.91), while the uninsured were more likely to undergo drainage (OR = 1.30, 95% CI: 1.16-1.46) or a colostomy only (OR = 1.70, 95% CI: 1.24-2.33). All patients without private insurance were more likely to die in hospital (Medicare OR = 1.29, 95% CI: 1.09-1.52; Medicaid OR = 1.55, 95% CI: 1.22-1.97; uninsured OR = 1.41, 95% CI: 1.07-1.87). CONCLUSION: In a nationally representative sample of patients with acute diverticulitis, patient management and outcome varied significantly by insurance status, despite adjustment for potential confounders. Providers might need to heighten surveillance for complications when treating patients without private insurance to improve outcome.

Cryopreserved arterial homografts vs silver-coated Dacron grafts for abdominal aortic infections with intraoperative evidence of microorganisms.

OBJECTIVE: The gold standard for the treatment of abdominal aortic infections remains controversial. Cryopreserved arterial homografts and silver-coated Dacron grafts have both been advocated as reasonable grafts. Direct clinical or experimental comparisons between these two treatment options have not been published before. This study compared cryopreserved arterial homografts and silver-coated Dacron grafts for the treatment of abdominal aortic infections in a contaminated intraoperative field. METHODS: From January 2004 to December 2009, 56 patients underwent in situ arterial reconstruction for an abdominal aortic infection. Patients with negative intraoperative microbiologic specimens were excluded. We compared 22 of 36 patients (61%) receiving cryopreserved arterial homografts (group A) vs 11 of 20 (55%) receiving a silver-coated Dacron graft (group B). Primary outcomes were survival and limb salvage; secondary outcomes were graft patency and reinfection. Direct costs of therapy were also calculated. RESULTS: Thirty-day mortality was 14% in group A and 18% in group B (P >.99), and 2-year survival rates were 82% and 73%, respectively (P = .79). After 2 years, limb salvage was 96% and 100%, respectively (P = .50), whereas graft patency was 100% for both groups. Major complications were an aneurysmal degeneration in group A and graft reinfection in group B (n = 2). Median direct costs of therapy (in US $) were $41,697 (range, $28,347-$53,362) in group A and $15,531 (range, $11,310-$22,209) in group B (P = .02). CONCLUSIONS: Our results show comparable effectiveness between cryopreserved arterial homograft and silver-coated Dacron graft in the contaminated operative field with respect to early mortality and midterm survival. Graft-inherent complications, aneurysmal degeneration for homografts, and reinfection for silver graft, were also observed. The in situ arterial reconstruction with homografts is nearly three times more expensive than with silver graft.

Nutritional management of enterocutaneous fistulas.

Enterocutaneous fistulas (ECF) may be challenging to manage due to the large volume of fluid losses, that may result in severe dehydration, electrolyte imbalances, malnutrition and sepsis. It is imperative that this group of patients receive adequate nutrition, as malnutrition and sepsis are the leading cause of death. ECF treatment is complex and based on various assessments, treatment can be medical/conservative management or surgical. Depending on the site of the fistula and the nutritional status of the patient, clinicians have to decide whether parenteral nutrition or enteral nutrition should be established. Fistuloclysis is a relatively novel procedure in which nutrition is provided via an enteral feeding tube placed directly into the distal lumen of a high output fistula. Although fistuloclysis is not feasible for all patients with ECF, for those that are eligible, the method appears to be an acceptable and safe method of maintaining and improving nutritional status.

Fistuloclysis can successfully replace parenteral feeding in the nutritional support of patients with enterocutaneous fistula.

BACKGROUND: Use of total parenteral nutrition (TPN) in patients with acute intestinal failure due to enteric fistulation might be avoided if a simpler means of nutritional support was available. The aim of this study was to determine whether feeding via an intestinal fistula (fistuloclysis) would obviate the need for TPN. METHODS: Fistuloclysis was attempted in 12 patients with jejunocutaneous or ileocutaneous fistulas with mucocutaneous continuity. Feeding was achieved by inserting a gastrostomy feeding tube into the intestine distal to the fistula. Infusion of enteral feed was increased in a stepwise manner, without reinfusion of chyme, until predicted nutritional requirements could be met by a combination of fistuloclysis and regular diet, following which TPN was withdrawn. Energy requirements and nutritional status were assessed before starting fistuloclysis and at the time of reconstructive surgery. RESULTS: Fistuloclysis replaced TPN entirely in 11 of 12 patients. Nutritional status was maintained for a median of 155 (range 19-422) days until reconstructive surgery could be safely undertaken in nine patients. Two patients who did not undergo surgery remained nutritionally stable over at least 9 months. TPN had to be recommenced in one patient. There were no complications associated with fistuloclysis. CONCLUSION: Fistuloclysis appears to provide effective nutritional support in selected patients with enterocutaneous fistula.

Timing of surgery for enterovesical fistula in Crohn's disease: decision analysis using a time-dependent compartment model.

OBJECTIVES: Previous decision analyses of inflam matory bowel diseases (IBD) have used decision trees and Markov chains. Occasionally IBD patients present with medical problems that are difficult or even impossible to phrase in terms of such established decision tools. This article aims to introduce modeling by a time-dependent compartment mode and demonstrate its feasibility for decision analysis in IBD METHODS: A Crohn's disease patient presented with a pelvic abscess and an enterovesical fistula. Being hesitant to operate in an acutely inflamed area, the surgeon recommended that the patient continue antibiotic therapy until the abscess had re solved. The gastroenterologist argued that the patient had already been treated with antibiotics for a prolonged time period and expressed concern that the patient's overall diminished health status would deteriorate by further delay of surgery. The occurrence of fistula, abscess, urinary tract infection, antibiotic therapy, surgical operation, and health-related quality of life were modeled as separate compartments, with time-dependent relationships among them. The simulation was carried out on an Excel spreadsheet. RESULTS: In the model, the surgeon's predictions were associated with rapid resolution of the pelvic abscess under antibiotic therapy and improvement of the patient's health status. The gastroenterologist's predictions resulted in a smaller decline in abscess size and further deterioration of the patient's health while waiting for a definitive treatment. The disagreement between surgery and gastroenterology arose from predicting different time courses for the individual disease events, in essence, from assigning different time constants to the time-dependent influences of the disease model. CONCLUSIONS: The compartment model provides a simple and generally applicable method to assess time dependent-changes of a complex disease. The present analysis also serves to illustrate the usefulness of such models in simulating disease behavior.

Vesico-colic fistulae in the Grampian region: presentation, assessment, management and outcome.

Over a 12-year period, 67 patients presented with a vesico-colic fistula. The mean age was 69 years (range 19-96 years), with symptoms predominantly referred to the urinary tract. Cystoscopy and barium enema confirmed the presence of a fistula in 60 and 44% of patients respectively. A computerized tomography (CT) scan, used in only seven patients, revealed the fistula in each case. The underlying pathology included diverticular disease (62%), carcinoma (27%) and inflammatory bowel disease (6%). Fifty-one patients proceeded to surgery, of whom 32 (63%) had a sigmoid/recto sigmoid resection with primary anastomosis, and 13 (25%) a Hartmann's procedure. A diverting colostomy alone was employed to palliate cases of widespread carcinoma. No patient subsequently had the Hartmann's reversed. In addition to colonic resection, 48 (92%) patients had a simultaneous bladder procedure, varying from simple oversew in 32 (70%) patients to cystectomy and ileal conduit in three (6%). Wedge excision with primary bladder closure was practised in 12 (24%). Fistula recurrence occurred in seven (14%) patients, and the 30-day mortality was 10%. Surgery for vesico-colic fistula has an appreciable morbidity and mortality, yet if offers the only hope of achieving permanent symptomatic control.

[Vesico-sigmoidal fistulas. Evaluation of the diagnostic performance of the complementary tests in our series]. / Fístulas vésico-sigmoideas. Valoración del rendimiento diagnóstico de las pruebas complementarias en nuestra serie.

We analyzed 14 cases of colovesical fistula that had been diagnosed and treated at the urology and gastroenterology and general surgery services of our hospital from 1986-1990. In 85.7% of the cases, the fistula had been caused by a tumor (adenocarcinoma of the colon) and in 14.3% by inflammatory disease (diverticulitis of the colon). All patients presented a varying degree of micturition syndrome; 30% had pneumaturia and 40% fecaluria. Cystoscopy proved to be the most effective in diagnosing colovesical fistula. It permitted visualization of the fistula or passage of fecal material to the bladder in 33% of the cases, while indirect endoscopic signs could be observed in 100%. Furthermore, it permitted the anatomopathological diagnosis of adenocarcinoma of the colon in 5 cases. We performed one-stage en bloc radical surgery in 57% of the cases, shotgun barrel discharge colostomy in 2 cases, exploration laparotomy in 3 and treatment was withheld in 1 case. The overall survival for the group submitted to radical surgery was 19.5 +/- 8.0 months. There were 4 deaths from metastasis, 2 from sepsis originating in the abdomen and the remaining deaths were due to iliofemoral venous thrombosis, cardiovascular disease and pneumopathy.

Aortoenteric fistula. Incidence, presentation recognition, and management.

Twenty-two patients developed one or more aortoenteric fistulae following aortic reconstruction with a dacron graft. Endoscopy was performed on 11 of these patients on 17 occasions and a preoperative diagnosis was made in eight patients. Fistulous communication was most common between the aorta and duodenum (60%), and a further 30% penetrated into the jejunum and ileum. The mean period from operation to time of diagnosis was 36 months and the mean length of bleeding was 25 days, allowing ample time for preoperative evaluation. Surgery was performed on 21 of the 22 patients with an overall mortality of 77%. The best surgical results were obtained with graft resection, closure of the aorta, and maintenance of circulation by an axillofemoral graft.