Rectocutaneous fistula and nonunion after TranS1 axial lumbar interbody fusion L5-S1 fixation: case report.

The authors report a case of rectal injury, rectocutaneous fistula, and pseudarthrosis after a TranS1 axial lumbar interbody fusion (AxiaLIF) L5-S1 fixation. The TranS1 AxiaLIF procedure is a percutaneous minimally invasive approach to transsacral fusion of the L4-S1 vertebral levels. It is gaining popularity due to the ease of access to the sacrum through the presacral space, which is relatively free from intraabdominal and neurovascular structures. This 35-year-old man had undergone the procedure for the treatment of degenerative disc disease. The patient subsequently presented with fever, syncope, and foul-smelling gas and bloody drainage from the surgical site. A CT fistulagram and flexible sigmoidoscopy showed evidence of rectocutaneous fistula, which was managed with intravenous antibiotic therapy and bowel rest with total parenteral nutrition. Subsequent studies performed 6 months postoperatively revealed evidence of pseudarthrosis. The patient's rectocutaneous fistula symptoms gradually subsided, but his preoperative back pain recurred prompting a revision of his L5-S1 spinal fusion.

Long-term prospective evaluation of topically applied 0.1% tacrolimus ointment for treatment of perianal sinuses in dogs.

OBJECTIVE: To evaluate effectiveness of a combination of topically applied tacrolimus, orally administered prednisone, and a novel-protein diet for treatment of perianal sinuses in dogs and to monitor clinical progress and owner management of the condition for 2 years. DESIGN: Noncontrolled clinical trial. Animals-19 dogs with perianal sinuses. Procedures-Perianal sinuses were diagnosed during physical examination, and dogs were placed on a 16-week treatment protocol consisting of topically applied 0.1% tacrolimus ointment, orally administered prednisone (tapering dose), and a novel-protein diet. Metronidazole was orally administered for the first 2 weeks. Anal sacculectomy was recommended whenever anal sacs were involved. Dogs were evaluated every month for the first 4 months and then every 6 to 12 weeks for 2 years. RESULTS: Perianal sinuses resolved completely in 15 of 19 dogs during the 16 weeks. In the remaining 4 dogs, the lesions markedly improved but failed to completely resolve. Three of these had anal sac involvement, and the owner of 1 dog had complied poorly with treatment instructions. During the 2 years following treatment, all dogs were maintained on intermittently applied tacrolimus ointment, 4 dogs also received prednisone every other day, and 11 dogs remained on the novel-protein diet. At the conclusion of the study, 13 of the 15 dogs that survived to that point were free of perianal disease. CONCLUSIONS AND CLINICAL RELEVANCE: The described protocol was effective and economical for resolving perianal sinuses. Dogs maintained on intermittent medications were unlikely to redevelop lesions. When the anal sacs were involved, anal sacculectomy appeared to improve the outcome.

Pulse granuloma in a rectocutaneous fistula.

Pulse granulomas are rare foreign body reactions to vegetable material characterized by hyaline rings or starch granules. Pulse granulomas have mainly been reported in association with lung aspirations, the oral cavity with a history of oral procedures and less frequently in intestinal fistulae, colonic diverticulae or stomach ulcers. Only one case involving the skin has been reported in a patient with jejunocutaneous and ileocutaneous fistulae. We report the second cutaneous pulse granuloma in a patient with a rectocutaneous fistula.

Does rich fiber diet accelerate the healing process of low-output colorectal fistulas?

The occurrence of an anastomotic leakage is a major therapeutic concern in colorectal surgery. Considering the outflow level of the fistula, a defunctioning stoma may be necessary to obtain closure. When the outflow is low and the intestinal transit is not interrupted, a colostomy is not mandatory but the healing process can be long. Here the author presents three consecutive cases of low output fistula treated by feeding with an enriched fiber diet. Closure of the fistulae occurred in a few days. The rationale of this alternative treatment is discussed.

Elemental diets in the management of Crohn's perianal fistulae.

Elemental diets have been used extensively in the routine management of patients with Crohn's disease during the past 2 years in this unit. We report our experience in 6 patients in whom perianal fistulae were present. Fistulae improved in 4 patients during elemental feeding; complete healing of fistulae occurred in one of them. No benefit was apparent in 2 patients, but in one the fecal stream had previously been diverted by transverse colostomy, and in the other fecal stasis was marked. The clinical significance of the observations and the difficulties of assessing diet therapy in this condition are discussed.

[Elementary diet as an alternative to parenteral feeding in severe gastrointestinal diseases]. / Elementaire Diät als Alternative zur intravenösen Ernährung bei schweren gastrointestinalen Krankheiten

21 patients with gastroenterological disease and indication for the use of intravenous nutrition received an elemental diet (ED) for 5-44 days. In 6 out of 8 patients with exacerbation of Crohn's disease remissions were achieved, apart from 3 persistent fistulas. In 5 out of 9 cases with various primary diseases and postoperative intestinal fistulas, spontaneous healing was observed. Furthermore, 2 patients with ulcerative colitis, 1 with radiation enteritis and 1 with pancreatitis were treated with ED. On ED, hemoglobin increased from 11.3 +/- 0.4 (m +/- SEM) to 12.0 +/- 0.5 g% (p less than 0.01) and serum albumin from 2.7 +/- 0.1 to 3.4 +/- 0.1 g% (p less than 0.001). Nitrogen requirements were studied in 11 patients receiving various quantities of ED. Nitrogen balance was found to be in equilibrium or positive in 7 patients, and negative in 4. In one patient with severe ulcerative colitis, fecal nitrogen losses were higher than urinary nitrogen losses. The unpleasant taste of ED resulting from free amino acids limited the ED supply in 3 patients and led to premature ending of ED administration in 3 other patients. In such cases ED may be given by nasogastric tube feeding. From the results presented it appears that ED is indicated in Crohn's disease and intestinal fistulas. However, the results obtained require confirmation by further observations and comparison with an intravenously fed control group.