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.

Successful bridging treatment and healing of enteric fistulae by vacuum-assisted closure (VAC) therapy and targeted drainage in patients with open abdomen.

PURPOSE: The object of this study was to investigate the bridging treatment of enteric fistulae by vacuum-assisted closure (VAC) therapy in patients with open abdomen. METHODS: We retrospectively analyzed patients who have been treated between 1 January 2007 and 31 December 2008 at the intensive care unit of the Department of General Surgery, Medical University Vienna. Control of the fistula was established by VAC therapy to bridge the patients to the time of the fistula resection. RESULTS: In the period of investigation, we treated nine (six men/three women) patients suffering from enteric fistulae with VAC therapy. The median age of the patients was 48 (range, 37-67) years. The median duration of VAC therapy was 76 (range, 53-128) days. The median length of stay in the intensive care unit was 44 (range, 25-127) days. The median APACHE II score was 23 (range, 18-25). The predicted mortality was 40%; the actual mortality was 11% (one patient). Primary fascial closure was achieved after median 91 (range, 89-92) days in three patients (33%) and secondary fascial closure after median 292 (range, 252-546) days in another three patients (33%). Fistulae were cured with VAC (five patients, 56%) and surgical resection (three patients, 33%). None of the patients developed a refistulation at the time of follow-up. CONCLUSIONS: Control of enteric fistulae by VAC therapy can lead to spontaneous fistula closure and is associated with a low mortality.

Regenerative medicine for digestive fistulae therapy: Benefits, challenges and promises of stem/stromal cells and emergent perspectives via their extracellular vesicles.

Despite current management strategies, digestive fistulae remain extremely debilitating complications associated with significant morbidity and mortality, generating a need to develop innovative therapies in these indications. A number of clinical trials and experimental studies have thus investigated the potential of stem/stromal cells (SCs) or SC-derived extracellular vesicles (EVs) administration for post-surgical and Crohn's-associated fistulae. This review summarizes the physiopathology and current standards-of-care for digestive fistulae, along with relevant evidence from animal and clinical studies regarding SC or EV treatment for post-surgical digestive fistulae. Additionally, existing preclinical models of fistulizing Crohn's disease and results of SC therapy trials in this indication will be presented. The optimal formulation and administration protocol of SC therapy products for gastrointestinal fistula treatment and the challenges for a widespread use of darvadstrocel (Alofisel) in clinical practice will be discussed. Finally, the potential advantages of EV therapy and the obstacles towards their clinical translation will be introduced.

Clinicopathological characteristics and prognosis of gastrointestinal stromal tumors containing air-fluid levels.

An air-fluid level within a gastrointestinal stromal tumor (GIST) is unusual and indicates the presence of a fistula within the lumen of the GI tract. Until recently, the optimal management of such patients was not clear-cut. This retrospective study investigated the clinicopathological characteristics, surgical procedures, pre-and post-operative management, and prognosis of patients with GIST containing an air-fluid level. Data of GIST patients, spanning 5 years, including 17 GIST patients with air-fluid levels in the experimental group and 34 GIST patients without air-fluid levels in the control group, were retrieved from two hospitals in China. The clinicopathological characteristics, types of surgery, management, and clinical outcomes of GIST patients were compared between the two groups. GISTs containing air-fluid levels were significantly different from GISTs without air-fluid levels regarding tumor morphology, NIH risk category, invasion of adjacent organs, and necrosis or ulceration. Most GIST patients with air-fluid levels (14/17, 82.4%) received open surgery, significantly higher than the 20.6% in the control group. Targeted therapy with Imatinib mesylate (IM) was implemented in all GIST patients in the experimental group (17/17, 100%); markedly higher than those (3/34, 8.8%) in the control group. During follow-up, recurrence and death rates (5.9% and 5.9%) in the experimental group were higher than those (2.9% and 0%) in the control group. Open surgery is commonly performed in GIST patients with air-fluid levels who also require targeted therapy with IM. The Torricelli-Bernoulli sign could be a risk factor, adversely affecting the patient's prognosis.

Intra-abdominal fistulas in surgically treated Crohn's disease patients.

BACKGROUND: Intra-abdominal fistulas occur in one-third of patients with Crohn's disease (CD). Although they are common, these fistulas may pose difficult problems for the surgeon. We assessed the clinical presentation of intra-abdominal fistulas in patients with CD and compared the clinicopathologic characteristics of CD with and without fistulas. METHODS: We analyzed consecutive laparotomy cases for 254 patients with CD between 1991 and 2008. Clinicopathologic data were abstracted from patient charts and a prospectively maintained database. Patient variables with and without fistulas were analyzed using the Fisher's exact test, chi-square test, and Student's t test. RESULTS: A total of 93 surgical procedures were performed on 83 patients (32.7%) who had at least one intra-abdominal fistula, revealing a total of 122 fistulas. Enteroenteric fistulas were the most common (30.3%), followed by enterocutaneous (23%), enterosigmoid (19.7%), enterocolonic (9.7%), and enterovesical (9.7%). Most cases (95.7%) underwent intestinal resection, with primary anastomosis in 77 of the cases (82.8%). There was no mortality, although 15 (16.1%) patients experienced postoperative complications. In the comparison of 270 cases with and without fistulas, cases with fistulas tended to have more frequent surgeries for perianal fistulas or abscesses (P = 0.001), more frequent intra-abdominal abscesses on CT (P = 0.044), and a higher incidence of combined small bowel and colonic disease (P < 0.001). CONCLUSIONS: The incidence and clinical features of fistulas were similar to those reported in previous studies of western patients. We identified that patients with CD and fistulas have more frequent other CD-related sepsis.

Erosion of anterior cervical plate into pharynx with pharyngotracheal fistula.

We report a 58-year-old woman who presented with dysphagia and recurrent episodes of coughing and choking during swallowing 10 years after anterior cervical discectomy and fusion with implantation of an anterior cervical plate. Barium esophagography revealed erosion of the cervical plate through the posterior wall of the pharyngoesophageal junction with an extraluminal collection that extended inferiorly as a track through the posterior wall of the trachea, producing a pharyngotracheal fistula. The pharyngeal perforation was repaired and the cervical hardware removed at surgery. This rare complication of anterior cervical discectomy and fusion should be recognized as a potentially serious but treatable long-term sequela of an anterior cervical plate.

Patient and general population values for luminal and perianal fistulising Crohn's disease health states.

BACKGROUND: In patients with Crohn's disease (CD), luminal disease activity paralleled by perianal fistulas may seriously impair health-related quality of life (HRQoL). Health utility values are not available from patients with CD that reflect the health loss associated with both luminal and perianal CD. OBJECTIVE: To generate utilities for luminal and concomitant perianal fistulising CD health states directly from patients and from members of the general public. METHODS: A cross-sectional survey was undertaken enrolling CD patients and a convenience sample of members of the general population. Respondents were asked to evaluate four common CD heath states [severe luminal disease (sCD), mild luminal disease (mCD), severe luminal disease with active perianal fistulas (sPFCD), and mild luminal disease with active perianal fistulas (mPFCD)] by 10-year time trade-off (TTO). In addition, patients assessed their current HRQoL by the TTO method. RESULTS: Responses of 206 patients (40.8% with perianal fistulas) and 221 members of the general population were analysed. Mean ± SD utilities among patients for sPFCD, sCD, mPFCD and mCD states were 0.69 ± 0.33, 0.73 ± 0.31, 0.80 ± 0.29 and 0.87 ± 0.26. Corresponding values in the general public were: 0.59 ± 0.31, 0.65 ± 0.29, 0.80 ± 0.26 and 0.88 ± 0.25. Patients with active perianal fistulas, previous non-resection surgeries, and higher pain intensity scores valued their current health as worse (p < 0.05). CONCLUSIONS: TTO is a feasible method to assess HRQoL in patients with perianal fistulising disease, often not captured by health status questionnaires. Utilities from this study are intended to support the optimization of treatment-related decision making in patients with luminal disease paralleled by active perianal fistulas.

Influence of Early Postoperative Feeding in Gastrointestinal Anastomotic Fistula Formation and Healing Time in Rabbits.

OBJECTIVES: To determine whether early postoperative feeding attenuates the inhibitory effects of intestinal anastomosis in rabbits. METHODS: After undergoing gastrointestinal anastomosis, 48 rabbits were randomly divided into experimental and control groups. The rabbits in the experimental group were fed a liquid diet beginning 24 h postoperatively, while the control rabbits received only total parenteral nutrition after the operation. Exploratory laparotomies were performed on four rabbits in each group 3, 5, 7, 10, and 15 days postoperatively, and the healing rate of the anastomosis, anastomotic bursting pressure, anastomotic breaking strength, and hydroxyproline content at the anastomosis were determined. RESULTS: The anastomoses healed in 91.6% (22/24) of the control group and 95.8% (23/24) of the experimental group. The anastomotic bursting pressure decreased remarkably in both groups 3 days postoperatively, reaching the lowest value. The anastomotic breaking strength did not differ between the two groups 3 days postoperatively, when both reached their lowest points, and both groups increased markedly and peaked 10 days postoperatively. The hydroxyproline content of the anastomosis was slightly lower in the experimental group 3 days postoperatively, although both groups peaked 7 days postoperatively. CONCLUSIONS: Early postoperative feeding does not increase the anastomosis healing time or rate of gastrointestinal anastomosis leakage.

Intracavitary Contrast-Enhanced Ultrasound in the Management of Post-Surgical Gastrointestinal Fistulas.

The goal of this study was to investigate intracavitary contrast-enhanced ultrasound (IC-CEUS) measures in the management of post-surgical gastrointestinal (GI) fistula throughout detection, treatment and follow-up. From June 2010 to August 2016, patients who were administered ultrasound contrast agent (UCA) via a drainage tube for IC-CEUS were enrolled and retrospectively analyzed. They were suspected of having GI anastomotic fistulas or had been found to have fluid collections with ultrasound that were accompanied by abdominal pain or fever after surgical procedures. Forty-two patients met the inclusion criteria and were enrolled into this study. Twenty-two were confirmed to have GI fistulas confirmed by standard references. None were detected by conventional ultrasound. Although IC-CEUS successfully detected GI fistulas in 16 patients, it missed GI fistulas in 6 patients. One patient was misdiagnosed with a GI fistula. The sensitivity, specificity, positive predictive value, negative predictive value and accuracy of the diagnosis of GI fistulas by IC-CEUS were 72.7% (16/22), 95.0% (19/20), 94.1% (16/17), 76.0% (19/25) and 83.3% (35/42), respectively. Twenty peritoneal fluid collections in 14 patients were related to fistulas by IC-CEUS based on the distribution of ultrasound contrast agents. Additional drainage was performed in 14 fistula-related fluid collections. Eight GI fistulas were judged to be cured after IC-CEUS re-evaluation, and the drainage tubes were removed from these patients. In conclusion, IC-CEUS can greatly improve the ability to diagnose post-surgical GI fistulas and may also play an important role in interventional treatment and follow-up.

Spontaneous right hepatic artery branch gallbladder fistula revealed by haemobilia and upper cataclysmic gastrointestinal bleeding.

Spontaneous right hepatic artery branch gallbladder fistula is a rare condition. Our case reported a spontaneous fistula between the right branch of the hepatic artery and the gall bladder. It constitutes a rare cause of haemobilia. In fact, the most common aetiology of haemobilia is traumatic or iatrogenic secondary to hepatobiliary surgery or interventions. Diagnosis of vascular-biliary fistula is not easy. The gallbladder endoluminal clot can mimic a mass, as in our patient. Selective arterial angiography is helpful in identifying the source of gastrointestinal haemorrhage. It can demonstrate the presence of arteriobiliary fistula. The differential diagnosis is arterial pseudoaneurysm in the vicinity of the vessel. Mini-invasive treatment of this fistula constitutes the best treatment. We here report a case of haemobilia with upper cataclysmic gastrointestinal bleeding revealing a spontaneous fistula between the right branch of the hepatic artery and the gall bladder.

Intraductal papillary mucinous carcinoma with atypical manifestations: report of two cases.

Intraductal papillary mucinous neoplasms (IPMNs) are a well-characterized group of mucin-producing cystic neoplasms of the clear malignant potential type. We report here two cases of intraductal papillary mucinous carcinoma (IPMC) with atypical manifestations. In one case, we discussed a pseudomyxoma peritonei caused by a ruptured IPMC. In the other case we discussed the fistulization of IPMC into the stomach and duodenum. These two cases suggest that IPMN can either spontaneously rupture causing mucinous materials to spill into the free abdominal cavity or directly invade adjacent organs resulting in fistula development.

Gastrocutaneous Fistula in a Patient with Locally Recurrent MSI-High Colorectal Cancer: Local Complications Arising from Therapeutic Response to Immune Checkpoint Blockade.

Colorectal cancers with high microsatellite instability (MSI-H) have distinct clinical features in terms of their prognosis, recurrence patterns, and sensitivity to immunotherapeutic agents. We present the case of a woman with a left-sided MSI-H colon cancer who had repeated recurrences concentrated exclusively in the left upper quadrant of the abdomen, including gastric involvement. Despite multiple surgical resections, radiation, and several lines of chemotherapy, her disease eventually eroded through the chest wall. Treatment with an immune checkpoint inhibitor produced a rapid clinical response with significant tumor necrosis; however, this necessitated surgical debridement that ultimately led to a large gastrocutaneous fistula. This case highlights the importance of recognizing locoregional tumor-associated complications that may result from robust therapeutic responses to immuno-oncology drugs, which are increasingly being used in clinical practice today.