Perianal tuberculosis presenting as a Fournier's gangrene.

Key Clinical Message: In the setting of Fournier's gangrene, atypical clinical manifestations and complications in an immunocompetent patient warrant consideration of perineal tuberculosis as a potential underlying cause. Abstract: Tuberculosis cutis orificialis is a rare form of extrapulmonary tuberculosis that affects the perianal region. Fournier's gangrene is an aggressive necrotizing fasciitis that primarily involves the perianal area and external genitalia. A previously healthy 38-year-old man presented with a left perianal abscess. His condition deteriorated, leading to septic shock and multiorgan dysfunction syndrome. A CT scan displayed extensive necrotizing fasciitis. Treatment included broad-spectrum antibiotics, numerous surgical perineal debridements, a transverse loop colostomy, and hyperbaric oxygen therapy. We believe the patient had pre-existing asymptomatic, non-diagnosed perianal tuberculosis, and a subsequent bacterial superinfection resulted in a perineal local abscess that progressed to severe Fournier's gangrene. The diagnosis of tuberculosis was confirmed through positive cultures and molecular identification in perineal biopsies. The patient experienced a complex clinical course with complications such as myocardial necrosis, acute respiratory distress syndrome, rhabdomyolysis with severe critical illness polyneuromyopathy and internal jugular thrombosis. Fournier's gangrene resulted in air dissection throughout the perineal fasciae, extending to the abdominal wall muscles resulting in an infected extraperitoneal spontaneous hematoma, probably caused by therapeutic anticoagulation. An extraperitoneal surgical drainage was performed. This case emphasizes the complexities in diagnosing and managing both perianal tuberculosis and Fournier's gangrene.

Fistula Recurrence: A Clinical Reality after Successful Endoscopic Closure of Laparoscopic Sleeve Gastrectomy Fistulas.

BACKGROUND AND AIMS: Laparoscopic sleeve gastrectomy (LSG)-related fistulas are important and potentially fatal complications. We aimed at determining the incidence, predictive factors, and management of recurrence of post-LSG fistulas. METHODS: This is a retrospective cohort study of 12 consecutive patients with LSG fistulas managed endoscopically between 2008 and 2013. We analyzed factors associated with recurrence of post-LSG fistulas and the efficacy of a primarily endoscopic approach to manage fistula recurrence. RESULTS: The average age at fistula detection after LSG was 43.3 ± 10.9 years, and 10 (83%) patients were female. The median interval between surgery and initial fistula detection was 14 (4-145) days. Fistulas were located at the gastric cardia in 9/12 patients. A median of 4 (1-10) endoscopies were performed per patient until all fistulas were successfully closed. The median follow-up was 30.5 (15-72) months. Fistula recurrence was detected in 3 (25%) female patients with an average age of 31.7 ± 7.9 years after a median of 119 (50-205) days of the initial fistula closure. Fistulas in all 3 patients recurred at the gastric cardia and were successfully managed endoscopically. There was a second recurrence in 1 patient after 6 months, and she was re-operated with anastomosis of a jejunal loop at the site of the fistula orifice at the gastric cardia. We did not find any factors at initial fistula detection that were significantly associated with fistula recurrence. There were no deaths related to initial fistula after LSG and fistula recurrence. CONCLUSIONS: A primarily endoscopic approach is an effective and safe method for the management of fistulas after LSG. Fistula recurrence occurred in 25% of patients and was managed endoscopically. KEY MESSAGES: Although we could not define predictive factors of post-LSG fistula recurrence, it is a clinical reality and can be managed endoscopically.

OBJECTIVOS: As fistulas pós-gastrectomia vertical (sleeve) laparoscópica (LSG) são complicações importantes e potencialmente fatais. O objectivo do estudo foi determinar a incidência, factores preditivos e manejo da recorrência de fistulas pós LSG. MÉTODOS: Estudo retrospectivo de 12 doentes com fistulas pós LSG manejados endoscopicamente entre 2008 e 2013. Analisámos factores associados à recorrência de fistulas pós LSG e a eficácia da abordagem endoscópica. RESULTADOS: Idade média na detecção das fistulas pós LSG foi de 43.3 ± 10.9 anos e 10 (83%) doentes eram mulheres. O intervalo mediano entre a cirurgia e a detecção da fistula inicial foi de 14 (4­145) dias. As fistulas localizaram-se no cárdia em 9/12 doentes. Foram realizadas em mediana 4 (1­10) endoscopias por doente até ao encerramento eficaz das fistulas. O tempo mediano de seguimento foi de 30.5 (15­72) meses. A recorrência das fistulas foi detectada em 3 (25%) doentes, todas mulheres, com idade média de 31.7 ± 7.9 anos, após um tempo mediano de 119 (50­205) dias após encerramento da fistula inicial. As recorrências das fistulas nas três doentes ocorreram no cárdia e foram manejados endoscopicamente.Houve uma segunda recorrência de fistula numa doente após 6 meses que foi reoperada com anastomose de ansa jejunal no local do orifício de fistula no cárdia. Não conseguimos determinar factores na altura da detecção da fistula inicial pós LSG significativamente associados com recorrência de fistulas. Não houve mortalidade associada às fistulas pós LSG (inicial ou recorrência). CONCLUSÕES: A abordagem primariamente endoscópica das fistulas pós LSG é um método eficaz e seguro. A recorrência de fistulas ocorreu em 25% dos doentes. As recorrências de fistulas pós LSG são manejáveis endoscopicamente. MENSAGENS CHAVE: Embora não tenhamos conseguido definir factores preditivos de recorrência de fistulas pós LSG, a recorrência de fistulas é uma realidade clínica e é manejável endoscopicamente.