Endoscopic submucosal dissection combined with clip for closure of gastrointestinal fistulas including those refractory to previous therapy.

BACKGROUND: Gastrointestinal (GI) fistula is a life-threatening condition and a therapeutic challenge. Endoscopic approaches include mucosal abrasion, clip closure, or stent diversion, with moderate success rates in the long term. We assessed whether fistula endoscopic submucosal dissection with clip closure (FESDC) could lead to complete resolution of fistulas even after failure of previous endoscopic therapy. METHODS: Patients with GI fistulas, including those with previous failed treatment, were retrospectively included. The primary outcome was long-term (> 3 months) success of fistula healing. Secondary outcomes included technical success, safety, and factors associated with FESDC success. RESULTS: 23 patients (13 refractory 57 %) were included. Tight immediate sealing was achieved in 19 patients (83 %; 95 % confidence interval [CI] 61 %-95 %). Long-term closure was achieved in 14 patients (61 %; 95 %CI 39 %-80 %), with median follow-up of 20 months. Complications occurred in two patients (9 %). Previous local malignancy (P = 0.08) and radiotherapy (P = 0.047) were associated with a higher risk of failure. CONCLUSION: This novel FESDC strategy was demonstrated to be safe and feasible for permanent endoscopic closure of GI fistulas. Further studies are warranted to determine the place of this technique in the management of chronic GI fistula.

Case 273: Pancreatic Duct-to-Portal Vein Fistula with Secondary Portal Vein Pyophlebitis-A Rare Complication of Chronic Pancreatitis.

HistoryA 55-year-old man with a history of chronic pancreatitis secondary to chronic alcohol abuse presented to the hospital with acute abdominal pain, generalized weakness, weight loss, and pyrexia. A clinical examination revealed he was tender to touch in the upper abdomen. Laboratory tests revealed a serum alkaline phosphatase level of 370 U/L (6.1 µkat/L) (normal range, 30-130 U/L [0.5-2.2 µkat/L]), a lipase level of 172 U/L (2.9 µkat/L) (normal range, 0-60 U/L [0-1.0 µkat/L]), a C-reactive protein level of 159 mg/L (1514 nmol/L) (normal value, <8.0 mg/L [76.2 nmol/L]), and a white cell count of 7 × 109/L (normal range, [4-11] × 109/L). During the present admission, the patient underwent urgent CT for his acute symptoms. His relevant medical history included a hospital admission 2 months earlier for abdominal discomfort. Given his history of chronic pancreatitis, baseline abdominal MRI was performed to determine the cause of his symptoms and to assess the pancreas.

Endoscopic management of inflammatory bowel disease-associated complications.

PURPOSE OF REVIEW: The main complications of inflammatory bowel disease (IBD) are strictures, fistulas, abscesses, and colitis-associated neoplasia. In addition to diagnosis, disease monitoring, and surveillance, endoscopy plays an important role in the management of those complications. This review is to provide up-to-date information in endoscopic treatment modalities for those complications. RECENT FINDINGS: The endoscopic therapy of IBD complication has evolved from balloon dilation of strictures to endoscopic stricturotomy, strictureplasty, stenting, fistulotomy, sinusotomy, and neoplasia ablation. These endoscopic approaches have provided minimally invasive treatment for those complications. SUMMARY: The advances in interventional IBD may be credited to our better understanding of the disease process and nature of targeted lesion, and execution of updated principles and techniques of endoscopy.

[Short-term efficacy of totally laparoscopic left colon cancer radical resection with overlapped delta-shaped anastomosis technique].

Objective: To evaluate the safety, feasibility and short-term efficacy of totally laparoscopic left colectomy for left colon cancer by using overlapped delta-shaped anastomosis technique for digestive tract reconstruction. Methods: A retrospective cohort study was conducted to collect the clinical data of 86 patients with left colon cancer who underwent laparoscopic surgery in Cancer Hospital of Chinese Academy of Medical Sciences from October, 2017 to February, 2019. The patients were divided into totally laparoscopic left-sided colectomy (TLLC) (treatment group, n=25 cases) and laparoscopic-assisted left-sided colectomy (LALC) (control group, n=61 cases). The intraoperative and postoperative data were compared between the two groups. Results: There were no surgical-related deaths in both groups. All the patients in the TLLC group underwent laparoscopic resection, while one patient in the LALC group transfer to open surgery. The operation time in TLLC group and LALC group were (164.5±42.3) min and (171.0±43.1) min, respectively, without statistically significant difference (P=0.516). However, the intraoperative blood loss of patients in the TLLC group was (36.4±22.7) ml, which was significantly less than (52.9±32.2) ml in the LALC group (P=0.026). The anastomosis time in the TLLC group was (39.1±6.5) min, which was significantly longer than (24.9±5.4) min in the LALC group (P<0.001). Postoperative exhaust time in the TLLC group was (2.6±0.5) days, which was significantly shorter than (3.3±0.8) days in the LALC group (P<0.001). The incision length in the TLLC group was (4.2±2.2) cm, significantly shorter than (7.0±2.5) cm in the LALC group (P<0.001). The length of the resected bowel was (21.0±7.3) cm in the TLLC group, which was significantly longer than (17.5±5.4) cm in the LALC group (P=0.037). The length of hospital stay in the TLLC group was (6.2±1.9) days, which was significantly shorter than (7.9±1.5) days in the LALC group (P<0.001). The incidences of postoperative complications in the TLLC group and LALC group were 0 and 4.9% (3/61), respectively, without statistically significant (P=0.553). No anastomotic complications occurred in both groups. During the follow-up period, neither group of patients was hospitalized again, and no tumor metastasis or recurrence occurred. Conclusions: It is safe and feasible to apply the TLLC with overlapped delta-shaped anastomosis in patients with left colon cancer. It has better short-term effects such as shorter incisions, faster recovery, and shorter postoperative hospital stays, and is worthy of further promotion.

The Value of C Reactive Protein and the Leukocytes in the Peritoneal Fluid in the Predicting Postoperative Digestive Fistulas.

Anastomotic fistulas in digestive surgery are a severe complication of the patient. The identification of paraclinical laboratory investigations which would allow an early diagnosis of fistulas would lead to the optimization of patient's management. We have performed a retrospective study on 100 cancer patients, with digestive tract surgeries, between May 2016 and December 2017, in the First Clinic of General surgery and Surgical Oncology from the Bucharest Oncology Institute. The postoperative follow-up included: the testing of the C reactive protein (CRP ), and also the monitoring of the number of leukocytes (Ld) from the abdominal cavity, with probes taken from the drainage tube, all in association with the number of leukocytes in the blood (Ls) in all patients (with or without digestive fistula). By calculating the values of these tests and comparing them always with the clinical evolution of the patients, and sometimes with other tests as well, one would confirm an early diagnosis of fistula. The data obtained have shown that in patients with digestive fistulae there is a rapid growth and maintaining of increased values of serum PCR and of the leukocytes from the peritoneal cavity, values to which we associated also an increase in blood leukocytes. The modifications appear with approx. two days before the appearance of clinical signs or their confirmation through imagery (ultrasound, computed tomography). The regular and standardized follow-up in days 1, 3 and 5 postoperatively of the PCR value in blood, of the number of leukocytes in the abdominal cavity and of the serum leucocytosis, increasing the value of these parameters, could allow the early identification of the patients with a risk of fistula and the rapid selection of those which need supplementary investigations and/or surgical intervention.

Clinical parameters and outcomes of necrotizing soft tissue infections secondary to gastrointestinal fistulas.

BACKGROUND: Necrotizing soft tissue infections (NSTIs) is severe surgical infections which can occur following trauma or abdominal surgery. NSTIs secondary to gastrointestinal (GI) fistula is a rare but severe complication. METHODS: A retrospective cohort study was performed on all subjects presenting with GI fistulas associated NSTIs were included. Clinical characteristics, microbiological profile, operations performed, and outcomes of patients were analyzed. RESULTS: Between 2014 and 2017, 39 patients were finally enrolled. The mean age were 46.9 years and male were the dominant. For the etiology of fistula, 25 (64.1%) of the patients was due to trauma. Overall, in-hospital death occurred in 15 (38.5%) patients. Microbiologic findings were obtained from 31 patients and Klebsiella pneumoniae was the most common species (41.0%). Eight patients were treated with an open abdomen; negative pressure wound therapy was used in 33 patients and only 2 patients received hyperbaric oxygen therapy. Younger age and delayed abdominal wall reconstruction repair were more common in trauma than in non-trauma. Non-survivors had higher APACHE II score, less source control< 48 h and lower platelet count on admission than survivors. Multiple organ dysfunction syndrome, multidrug-resistant organisms and source control failure were the main cause of in-hospital mortality. CONCLUSIONS: Trauma is the main cause of GI fistulas associated NSTIs. Sepsis continues to be the most important factor related to mortality. Our data may assist providing enlightenment for quality improvement in these special populations.

The Importance of the Nutritional Factor and the Stage of the Disease in Postoperative Fistula in Patients with Gastric Cancer.

Introduction: In gastric cancer there are multiple local and general risk factors for the occurrence of postoperative fistulas. In the present study, we proposed to analyse the role of the preoperative nutritional state and nutritional therapy along with the disease stage, the age and the sex of patients in the occurrence of fistulas. Material and method: This retrospective study included 158 patients operated for gastric cancer in Surgery Department of Bucharest Oncology institute between January 2010 and December 2016 in which we analysed the incidence of anastomotic fistula according to the nutritional status, disease status, age and sex of the patients. Results: The global incidence of fistulas was of 11%, out of which 8 % were fistulas of the duodenal stump and 3.19% fistulas of the eso-jejunal anastomosis. Out of the 30 patients with weight loss and parenteral nutrition in the preop period, we had 4 fistulas (13%), and out of the 36 patients with weight loss and nutritional measures in the postop we had 5 fistulas (14%), also, out of the 24 patients with weight loss and without nutritional intervention, we had 5 fistulas (21%), finally, out of the 68 patients without weight loss we had fistulas in 4 patients (6%).. The incidence of fistulas was 5% in patients with stage I, II and III and 24% in stage IV patients. The distribution of fistulas according to the age of the patients showed a much higher incidence of fistulae in patients over 70 years old. Conclusions: The number of postoperative fistulas was higher in the advanced stages of the disease (p=0.027) and in patients over 70 years old (p=0.047) and the differences were statistically significant. The difference between the number of fistulae occurred in patients who had weight loss but did not receive nutritional support from those who received this support was not statistically significant (p 0.001).

Analysis of risk factors related to gastrointestinal fistula in patients with severe acute pancreatitis: a retrospective study of 344 cases in a single Chinese center.

BACKGROUND: Gastrointestinal fistula (GIF) in severe acute pancreatitis (SAP) is considered as a sparse episode and studied sporadically in the literature. There is paucity of data on the prediction of the effect on risk of GIF in patient with SAP. This study was aimed to investigate risk factors related to GIF in the development of SAP. METHODS: The clinical data of 344 patients with SAP from 2011 to 2016 were reviewed retrospectively. All patients were divided into the GIF group and the non-GIF group, and their data analyzed with respect to 15 parameters were applied to explore potential risk factors for GIF in patients with SAP. RESULTS: Of the 344 eligible patients, 52 (15.12%) progressed to GIF. Only occurrence of infected pancreatic and extra-pancreatic necrosis (IPN) (P = 0.004, OR = 3.012) and modified CT severity index (MCTSI) (P = 0.033, OR = 1.183) were proved to be independent risk factors for GIF in patients with SAP, and blood type B (P = 0.048, OR = 2.096, 95% CI: 0.748-3.562) indicated weaker association of risk factor for GIF. The early (48-72 h after admission) enteral nutrition (EEN) (P = 0.016, OR = 0.267) acted as a protective factor. CONCLUSIONS: Occurrence of IPN and high MCTSI are independent risk factors for the development of GIF in patients with SAP, blood type B reveals a potential correlation with GIF in patients with SAP. EEN is helpful to prevent the progression of GIF secondary to SAP.

Clinical features of hidradenitis suppurativa and Crohn disease: what do these two entities have in common? / Aspectos clínicos de la hidradenitis supurativa y de la enfermedad de Crohn: ¿qué hay en común?

Hidradenitis suppurativa (HS) and Crohn disease (CD) are chronic, recurrent inflammatory diseases. They share certain clinical characteristics and flares are common in both. Both entities are usually diagnosed between the second and third decades of life and share risk factors such as smoking and overweight. In CD, as in HS, acute untreated episodes of inflammation can lead to sequels such as abscesses, fistulas and stenosis. Consequently, early management is of the utmost importance. Some patients have both diseases. The estimated prevalence of SH in CD patients is 12.4%-17.9%, while the prevalence of CD in HS patients is around 3%. The presence of HS in patients with inflammatory bowel disease (IBD) is associated with an earlier onset of IBD and with more frequent need for anti-TNF-alpha therapy and surgical resection.

Digestive Decompression to Prevent Digestive Fistulas After Gastric Neoplasm Resection.

Introduction: The risk of digestive fistula in patients operated for gastric neoplasm is increased due to biological imbalances generated by the cancer's progression, by diagnosis in advanced stages, and by the scale of intervention. Under these circumstances the use of some technical means to protect digestive sutures in these patients is useful. AIM: To analyse the efficiency of technical means to protect the digestive sutures in patients operated in various stages of development of gastric cancer. Material and Methods: We conducted a retrospective study on a group of 130 patients operated for gastric cancer in the 1st General Surgery and Oncology Clinic of the Bucharest Institute of Oncology, between 2010-2014. Results: 38.46% of the patients in the study group presented stage IV cancer with multiple complications and biological imbalances. 52 total gastrectomies and 40 gastric resections were carried out, while in 34 patients palliative "tumour excisions" or other types of palliative surgery were performed. In 15 of the cases with gastric resection a duodenal decompression probe was used, while in 13 of the patients with total gastrectomy an oeso-jejunal aspiration probe together with an oeso-jejunal feeding probe were used as additional technical measures to prevent fistula formation. The incidence of duodenal stump fistula was 7.69%, that of oeso-jejunal anastomosis fistula was 2.3%, with an overall mortality of 3.07% and that of gastro-jejunal anastomosis fistula was 0.76%. CONCLUSION: Given the risk of fistula development in patients with gastric cancer, as well as the increased risk in advanced stages of cancer development, we consider that the use of technical means of protection of digestive sutures is beneficial and opportune, lowering the incidence of fistulas, reducing their output, pathophysiological effects, and mortality.

Therapeutic approach to Crohn disease: possible parallels with hidradenitis suppurativa. / Abordaje terapéutico de la enfermedad de Crohn: posibles paralelismos con la hidradenitis supurativa.

The current controversy in the setting of dermatology surrounding the treatment of inflammatory diseases, and specifically hidradenitis suppurativa, bears strong similarities with the debate concerning inflammatory bowel disease (IBD) that took place several years ago. That debate led to new perspectives on this disease and, in particular, its treatment after the development of biological agents.

Endoscopic treatment of fistula after sleeve gastrectomy: results of a multicenter retrospective study.

BACKGROUND AND STUDY AIMS: Fistula is the main complication of laparoscopic sleeve gastrectomy (LSG), for which healing is difficult to achieve. The aims of the study were to evaluate the efficacy of interventional endoscopy for post-LSG fistula treatment, to evaluate various endoscopic techniques used and identify their complications, and to identify predictive factors of healing following endoscopic treatment. PATIENTS AND METHODS: This retrospective multicenter study included patients with post-LSG fistula. Therapeutic procedures were evaluated, taking into account complications and healing times. Endoscopic procedures were considered to have promoted healing if no other surgical procedure was performed. Predictive factors of healing were identified by univariate and multivariate analysis. RESULTS: A total of 110 patients were included, of whom 6 (5.5 %) healed spontaneously, 81 (73.6 %) healed following endoscopic treatment, and 19 (17.3 %) healed following surgery. Healing rates following endoscopic treatment were 84.4 % in the first 6 months of treatment (65/77), 52.4 % for treatment lasting 6 - 12 months (11/21), and 41.7 % after 12 months of treatment (5/12). A drainage procedure (surgical, endoscopic, or percutaneous) was performed in 92 patients (83.6 %). A total of 177 esogastric stents were placed in 88 patients (80.0 %). Surgical debridement, clip placement, glue sealing, and plug placement were also performed. Multivariate analysis identified four predictive factors of healing following endoscopic treatment: interval < 21 days between fistula diagnosis and first endoscopy (P = 0.003), small fistula (P = 0.01), interval between LSG and fistula ≤ 3 days (P = 0.01), no history of gastric banding (P = 0.04). CONCLUSION: Endoscopic treatment facilitated healing of post-LSG fistula in 74 % of patients. Early endoscopic treatment increased the likelihood of success, and was most effective during the first 6 months of management. After this point, surgical treatment should be considered.

Usefulness of over-the-scope clipping system for closing digestive fistulas.

BACKGROUND AND AIM: Therapeutic endoscopy has recently evolved into the treatment of complex gastrointestinal (GI) postoperative leakage, especially with over-the-scope clips (OTSC). We describe our 2-year experience of 30 patients treated for digestive fistulas using the OTSC device. METHODS: This was a retrospective study conducted on patients referred for GI fistulas in two French hospitals. Technical aspects, clinical outcomes and closure rates were recorded. RESULTS: Thirty patients were treated for GI leaks: 19 (63%) had a gastric fistula after laparoscopic sleeve gastrectomy (LSG); the others had rectovaginal, urethrorectal, rectovesical, gastrogastric, gastrocutaneous, esophagojejunal fistulas and colorectal anastomotic leak. Average follow up was 10.4 months. Eighteen (60%) had undergone previous endoscopic or surgical treatment. Orifice size was 3-20 mm (average 7.2 mm). Successful OTSC placement was achieved in 30 out of 34 attempts. There were four intraoperative undesired events (13.3%) but these were successfully managed. Overall success rate was 71.4% and 16 patients (53%) recovered with primary efficacy. Six patients (20%) required a subsequent endoscopic treatment. Eight patients (26.7%) required surgery for failure. In nine cases, we used one or more additional endoscopic procedures concomitantly with the OTSC combining self-expandable metal stents, standard clips and glue injection. Healing rate after LSG fistula was 88.9%, which was significantly higher than the overall rate (P = 0.01). CONCLUSION: OTSC placement seems to be safe and effective for the treatment of GI fistulas. Better results were seen in leaks after LSG.

[Spontaneous cutaneous fistula of hydatid liver cysts]. / La fistulisation cutanée spontanée des kystes hydatiques du foie.

BACKGROUND: Spontaneous cutaneous fistula of hydatid liver cysts is a rare complication. Its genesis involves anatomic factors as well as other local factors. AIMS: An exhaustive literature review was conducted to identify the characteristics of this complication, treatment modalities and the results obtained. PATIENTS AND METHODS: An exhaustive bibliographic search was made for all articles published in French and English relating to parietal complications of hydatid liver cyst, from which we retained only those involving cases of cutaneous cyst fistulas (communicating rupture), to which we added our own case. RESULTS: Seventeen cases of cystocutaneous fistula have been reported. The reason for consultation was productive cutaneous fistula. Morphological investigations were highly evocative of the diagnosis. Thirteen patients were treated by surgery, two underwent percutaneous debridement, and two declined treatment. DISCUSSION: Cutaneous fistula constitutes a rare mode of discovery of hydatid cyst. Fistulography and CT scan are extremely useful for diagnosis. Percutaneous debridement of the hydatid cyst represents a debatable alternative to surgical therapy.

Digestive fistulas after cytoreductive surgery & HIPEC in peritoneal carcinomatosis.

PURPOSE: The development of digestice fistulas is a complication of gastrointestinal operations during cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). In this article we present the incidence, management and outcome of enterocutaneous digestive fistulas after CRS and HIPEC. METHODS: Over the past 10 years (2005-2014), 184 patients with peritoneal carcinomatosis underwent CRS and HIPEC. HIPEC was administered in the operating room immediately after CRS, but in 48 (26%) patients this happened before the formation of intestinal anastomosis or repair of seromuscular tears, using the open (coliseum) technique; in the remaining 137 (74%) patients the anastomoses were performed before HIPEC. All patients were operated on by the same surgical team. RESULTS: Of the 185 patients 16 (8.6%) developed an enterocutaneous digestive fistula. Spontaneous fistula closure was observed in 14 (87.5%) patients. The median duration of spontaneous closure was 18 days (range 9-56). Reoperation was needed in 2 (12.5%) patients. There were 2 (12.5%) deaths. CONCLUSION: CRS and HIPEC is a well-known treatment modality for peritoneal carcinomatosis. The incidence of digestive fistulas is increased a little compared to that of conventional digestive surgery.

Bevacizumab doubles the early postoperative complication rate after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal carcinomatosis of colorectal origin.

BACKGROUND: Patients with stage IV colorectal cancer and peritoneal carcinomatosis are increasingly treated with curative intent and perioperative systemic chemotherapy combined with targeted therapy. The aim of this study was to analyze the potential impact of bevacizumab on early morbidity after cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC) in patients with peritoneal carcinomatosis of colorectal origin. METHODS: From 2004 to 2010, in three referral centers, 182 patients with colorectal carcinomatosis were treated with complete cytoreduction followed by HIPEC after either preoperative systemic chemotherapy alone or in combination with bevacizumab. Because there was no control on treatment allocation, propensity score methods were used to control for this bias. RESULTS: The median time from discontinuation of bevacizumab to HIPEC was 7 weeks (range 6-10 weeks). Major morbidity was greater in the bevacizumab group (34 vs. 19 %, p = 0.020). Nine patients died postoperatively, 5 (6.2 %) in the bevacizumab group (n = 80) and 4 (3.9 %) in the group treated with chemotherapy alone (n = 102) (p = 0.130). The rate of digestive fistulas was greater in the bevacizumab group, although not statistically significant (18 vs. 10 %, p = 0.300). The effect of bevacizumab on major morbidity (including death) was found to be statistically significant (odds ratio 2.28, 95 % confidence interval 1.05-4.95) (p = 0.04). CONCLUSIONS: Administration of bevacizumab before surgery with complete cytoreduction followed by HIPEC for colorectal carcinomatosis is associated with twofold increased morbidity. The oncologic benefit of bevacizumab before HIPEC remains to be evaluated.

THE ROLE OF NUCLEAR IMAGING IN TRAUMATIC HEPATOPLEURAL FISTULA: A CASE REPORT.

Penetrating injuries are a major cause of mortality and morbidity. The most common diagnostic tool used in this setting is CT scan. We present a case of a traumatic hepatopleural fistula demonstrated by hepatobiliary scintigraphy. Traumatic abdominal injuries to the liver and diaphragm can result in complications, whose detection by CT scan is not always straightforward. Hepatobiliary scintigraphy is very useful in the search of bilious pleural effusions.

The use of gastrostomy procedures in HNC patients.

PURPOSE: To analyse the gastrostomy procedures performed in HNC patients admitted to Coltea Clinical Hospital in order to underline the similarities and differences to the data published worldwide. PATIENTS AND METHODS: Our retrospective study contains 64 HNC cases that met the inclusion criteria between 2008 and 2011. RESULTS AND DISCUSSIONS: The study group presents numerous specific characteristics (a larger number of cases aged over 55 than younger patients; elective use of classic gastrostomy instead of newer techniques; approximately two thirds of the gastrostomies were performed in patients with laryngeal carcinoma; only one third approximately of the cases benefited from prophylactic gastrostomy; etc.). CONCLUSIONS: 22% of the gastrostomies were made after the appearance of a pharyngocutaneous fistula. Therefore we will begin a future prospective study in order to ascertain the value of prophylactic PEG in preventing the appearance of pharyngocutaneous fistulas.