Robotic management of primary cholecystoduodenal fistula: A case report and brief literature review.

BACKGROUND: Cholecystoduodenal fistula (CDF) arises from persistent biliary tree disorders, causing fusion between the gallbladder and duodenum. Initially, open resection was common until laparoscopic fistula closure gained popularity. However, complexities within the gallbladder fossa yielded inconsistent outcomes. Advanced imaging and robotic surgery now enhance precision and detection. METHOD: A 62-year-old woman with chronic cholangitis attributed to cholecystoduodenal fistula underwent successful robotic cholecystectomy and fistula closure. RESULTS: Postoperatively, the symptoms subsided with no complications during the robotic procedure. Existing studies report favourable outcomes for robotic cholecystectomy and fistula closure. CONCLUSIONS: Our case report showcases a rare instance of successful robotic cholecystectomy with CDF closure. This case, along with a review of previous cases, suggests the potential of robotic surgery as the preferred approach, especially for patients anticipated to face significant laparoscopic morbidity.

Endoscopic Treatment of Duodenocolic Fistula Caused by Migrating Biliary Stents.

BACKGROUND Endoscopic biliary stent implantation is a recognized and effective method for the treatment of benign and malignant diseases of the bile duct and pancreas, ensuring smooth bile drainage. Currently, stent migration is considered a long-term and complex process, and in most cases, stents are removed through endoscopy or expelled from the body through the intestinal cavity. In rare cases, stents lead to formation of duodenocolic fistulas. CASE REPORT We report a case of duodenal colon fistula caused by a biliary stent penetrating the duodenum and entering the ascending colon. We removed the stent through endoscopy and clamped the fistulas of the colon and duodenum separately with titanium clips. Due to the presence of large common bile duct stones, nasobiliary drainage was performed again. Later, laparoscopic choledocholithotomy was performed, and the patient was discharged after rehabilitation. CONCLUSIONS ERCP endoscopy must consider the possibility of stent displacement in patients with biliary stents. In the case of CBD biliary stent dislocation in the patient, continuous abdominal plain films and physical examinations are required until spontaneous discharge is confirmed. In addition, for patients with benign bile duct stenosis undergoing biliary drainage, doctors should urge them to return to the hospital on time to remove the stent. For patients with postoperative abdominal pain or peritonitis symptoms, abdominal CT scan confirmation is required and early intervention should be considered.

[Stepwise treatment of complex intestinal fistulas and strategies of nutritional support treatment].

Intestinal fistula is one of the common diseases and complications in abdominal surgery. It does not only cause severe abdominal infections but also leads to obstruction, bleeding, malnutrition, and may develop into complex intestinal fistulas, resulting in increased challenges in treatment, elevated treatment costs, and increased risk of patient mortality. At present, the treatment of intestinal fistula mainly adopts a three-stage approach: (1) early diagnosis, (2) mid-term nutritional support treatment, and (3) definitive surgical treatment. Nutritional support treatment can significantly reduce patient mortality and improve recovery. Due to the difficulty, complexity, and diversity of intestinal fistula treatment, and the fact that complex intestinal fistulas are currently a challenge in the treatment of intestinal fistulas, this article will introduce the progress and difficulties at different stages, and explore the future treatment direction of intestinal fistulas from the perspective of interdisciplinary cooperation.

Jejunovesical Fistula Diagnosis After Normal Vaginal Delivery: A Case Report.

Enterovesical fistula represents an abnormal communication between the intestine and bladder. The causes are diverticulitis (56.3%), malignant tumours, which are located mainly in the intestine (20.1%), and Crohn's disease (9.1%). Other causes include iatrogenic injury (3.2%); trauma; foreign bodies in the intestinal tract; radiotherapy; chronic appendicitis; tuberculosis; and syphilis. Normal vaginal delivery as a cause for enterovesical fistula has not been reported in many publications yet. We report a case of a 30-year-old female, who developed an jejunovesical fistula after normal vaginal delivery. It was diagnosed after diagnostic cystoscopy and computed tomography of the abdomen and pelvis. There was jejuno-vesical fistula. Resection of the segment of the jejunum with side-to-side anastomosis with bladder repair was done. A follow-up cystogram was done which showed no contrast extravasation into the peritoneum. The patient was followed up for 9 months after surgery. Keywords: case reports; fistula; jejunum; urinary bladder.

A Rare Case of Retroperitoneal Abscess Caused by Nephro-Colic Fistula Resulting from Staghorn Calculus.

BACKGROUND Nephro-colic fistulas are uncommon, generally caused by local inflammation, trauma, or neoplasia affecting the kidney or the colon. Their association with a coralliform stone is described in a few case reports, but their management is difficult and differs quite a lot, depending on the clinical situation. We report an atypical clinical case of a reno-colic fistula associated with a staghorn calculus. This case adds to the literature an iconography rarely found. CASE REPORT A 68-year-old woman presented to the Emergency Department with respiratory symptoms and chronic abdominal pain. The biological results showed a high inflammatory syndrome. The radiological assessment revealed a retroperitoneal and left retro-renal abscess, attributed to a left nephro-colic fistula associated with the partial passage of a lithiasis within the colonic lumen. Colonoscopy confirmed the diagnosis. Multiple recurrences of diverticulitis in this region could be the origin of the complication. First, the patient was treated with antibiotic therapy and radiological drainage. Second, she benefited from a left nephrectomy, left segmental colectomy, and splenectomy. The clinical and radiological evolution were favorable after surgery. The follow-up was disrupted by hospitalizations in the Cardiology Department for cardiac decompensation. CONCLUSIONS Kidney stones along with local inflammatory phenomena can be the cause of a nephro-colic fistula. Due to the lack of guidelines in such cases, their diagnosis and management are difficult to ascertain. Surgery is the right course of treatment.

Treating a Bypass with Bypass Surgery: Repair of a Duodeno-sigmoid Fistula Complicating Acute Diverticulitis.

Diverticular disease is common in Western countries; one-third of patients with diverticular disease develop diverticulitis during their lifetime of whom 5% may experience serious complications. We describe a rare complication of diverticulitis: a duodeno-colic fistula in a patient with an elongated sigmoid colon (dolicosigma). The patient complained of abdominal pain, diarrhea, weight loss, and feculent vomiting. Radiological studies and gastroscopy demonstrated a fistula between the second portion of the duodenum and the sigmoid colon. Curative surgery cured the fistula and completely resolved its associated signs and symptoms.

Multifaceted surgical approach of combined thoracoretroperitoneal incision and midline abdominal incision for a secondary aortoenteric fistula.

BACKGROUND: We report a one-stage surgery to the case of secondary aortoenteric fistula (sAEF) after prosthetic reconstruction of abdominal aortic aneurysm, by multifaceted approach. CASE PRESENTATION: A 63-year-old male was admitted to our unit under diagnosed of sAEF after prosthetic reconstruction of abdominal aortic aneurysm, and a pseudoaneurysm of thoracoabdominal aorta due to infection. The patient underwent emergency operation. Firstly, we placed the patient in a modified right lateral decubitus position and performed thoracoabdominal aortic replacement with retroperitoneal approach by thoracoretroperitoneal incision which combined thoracotomy and pararectal incision, and secondly, we changed to a supine position and performed closure of the duodenal fistula and omental flap transposition by midline abdominal incision. The patient was doing well without complications. CONCLUSIONS: A one-stage, multifaceted surgical approach covering both prosthetic reconstruction of thoracoabdominal aorta and closure of sAEF with omentopexy is reasonable and useful strategy.

Lending a hand: The utility of hand-assisted laparoscopic surgery in diverticulitis with fistula.

BACKGROUND: Current guidelines recommend elective colectomy for the management of diverticulitis-associated fistulas. These cases present considerable operative challenges, and surgical approaches and fistula tract management vary widely. Hand-assisted laparoscopic surgery offers the benefits of minimally invasive surgery while maintaining the tactile advantages of open surgery. This study aims to evaluate outcomes of hand-assisted laparoscopic surgery colectomy for diverticulitis-associated fistulas, fistula tract, and urinary catheter management. METHODS: A retrospective review of patients with diverticulitis-associated fistula who underwent elective hand-assisted laparoscopic surgery colectomy between January 2, 2008, and September 8, 2022, was performed. Patients with Crohn disease or who underwent emergency surgery were excluded. RESULTS: Seventy patients were included; the mean patient age was 64.1 ± 14.8 years, and the mean body mass index was 30.9 ± 9.1 kg/m2. Colovesical fistulas were most common (n = 48; 68.6%), followed by colovaginal fistulas (n = 22; 31.4%). The median operative time was 186 minutes. Conversion to an open approach occurred in 4 cases (5.7%). The fistula tract remnant was left without intervention in 35 patients (50%), and omental coverage occurred in 23 cases (32.9%). The median duration of the urinary catheter was 3 days (range = 1-63). There were no postoperative urine leaks. Three patients (4.3%) were readmitted in ≤30 days. There were no 30-day mortalities. CONCLUSION: The challenges of colectomy for diverticulitis-associated fistulas can be mitigated using the hand-assisted laparoscopic surgery technique. We found a low conversion-to-open rate, falling below rates reported for laparoscopic colectomy. There were no cases of postoperative urine leak, suggesting that no intervention or omental coverage is a safe approach to fistula tract management.

A Modern Series of Secondary Aortoenteric Fistula - A 19-Year Experience.

OBJECTIVES: Secondary aortoenteric fistula is a rare and life-threatening condition. Clear evidence on the ideal therapeutic approach is largely missing. This study aims to analyze symptoms, etiology, risk factors, and outcomes based on procedural details. PATIENTS AND METHODS: All patients with secondary aortoenteric fistula admitted between 2003 and 2021 were included. Patient characteristics, surgical procedure details, and postoperative outcomes were analyzed. Outcomes were stratified and compared according to the urgency of operation and the procedure performed. Descriptive statistics were used. The primary endpoint was in-hospital mortality. RESULTS: A total of twentytwo patients (68% male, median age 70 years) were identified. Main symptoms were gastrointestinal bleeding, pain, and fever. From the twentytwo patients ten patients required emergency surgery and ten urgent surgery. Emergency patients were older on average (74 vs 63 years, P = .015) and had a higher risk of postoperative respiratory complications (80% vs 10%, P = .005). Primary open surgery with direct replacement of the aorta or an extra-anatomic bypass with an additional direct suture or resection of the involved bowel was performed in sixteen patients. In four patients underwent endovascular bridging treatment with the definitive approach as a second step. Other two patients died without operation (1x refusal; 1x palliative cancer history). In-hospital mortality was 27%, respectively. Compared to patients undergoing urgent surgery, those treated emergently showed significantly higher in-hospital (50% vs 0%, P = .0033) mortalities. CONCLUSION: Despite rapid diagnosis and treatment, secondary aortoenteric fistula remains a life-threatening condition with 27% in-hospital mortality, significantly increased upon emergency presentation.

Revascularization and Digestive Tract Repair in Secondary Aortoenteric Fistula Using a Single-Center in Situ Revascularization Strategy.

BACKGROUND: Information regarding optimal revascularization and digestive tract repair in secondary aortoenteric fistula (sAEF) remains unclear. Thus, reporting treatment outcomes and presenting comprehensive patient details through a structured treatment approach are necessary to establish a treatment strategy for this rare, complex, and fatal condition. METHODS: We performed a single-center retrospective review of consecutive sAEF managed based on our in situ revascularization and intestinal repair strategy. The primary endpoint of this study was all-cause mortality, and secondary endpoints were the incidence of in-hospital complications and midterm reinfections. RESULTS: Between 2007 and 2020, 16 patients with sAEF, including 13 men (81%), underwent in situ revascularization and digestive tract repair. The median follow-up duration for all participants was 36 (interquartile range, 6-62) months. Among the participants, 81% (n = 13), 13% (n = 2), and 6% (n = 1) underwent aortic reconstruction with rifampin-soaked grafts, unsoaked Dacron grafts, and femoral veins, respectively. The duodenum was the most commonly involved site in enteric pathology (88%; n = 14), and 57% (n = 8) of duodenal breaks were repaired by a simple closure. Duodenum's second part-jejunum anastomosis was performed in 43% of patients (n = 6), and 19% of the patients (n = 3) died perioperatively. In-hospital complications occurred in 88% patients (n = 14), and the most frequent complication was gastrointestinal. Finally, 81% patients (n = 13) were discharged home. Oral antibiotics were administered for a median duration of 5.7 months postoperatively; subsequently, the participants were followed up carefully. Reinfection was detected in 6% of the patients (n = 1) who underwent reoperation without any complications. The 1-year and 3-year overall survival rates of participants were 75% (n = 12) and 75% (n = 9), respectively, and no sAEF-related deaths occurred, except perioperative death. CONCLUSIONS: Surgical intervention with contemporary management based on our vascular strategy and digestive tract procedure may be a durable treatment for sAEF.

Ileal conduit to small intestine fistula following extensive abdominopelvic resection and radiation for metastatic colon cancer.

A woman in her mid-60s presented with decreased output from urostomy, which was an opening from the neobladder (ileal conduit). Presentation was preceded by a 6-month history of alternating faecaluria and increased colostomy output. Laboratory studies were notable for normal anion gap metabolic acidosis. Creatinine level of the colostomy output was 17.7 mg/dL, a finding indicative of the presence of urine in the sample. CT enterography and X-ray loopogram confirmed neobladder to small intestine fistula.Neobladder creation is commonly performed in patients with bladder cancer requiring resection. Fistulas between the neobladder and intestine are observed in fewer than 2.7% of cases. The patient's history of extensive abdominopelvic resection, colostomy creation and radiation likely contributed to fistula development. We highlight the need for a high index of suspicion for a fistula in a patient with a neobladder experiencing recurrent urinary tract infections or a high colostomy output concurrently with low neobladder output.

Iatrogenic enterovesical fistula secondary to a permanent urinary catheter.

An enterovesical fistula is a rare entity resulting from inflammatory, neoplastic and iatrogenic processes. It can manifest clinically as pneumaturia and recurrent urinary tract infections. Its diagnosis is supported by imaging examinations and its treatment is primarily surgical.

A multicenter case-control study on postoperative intestinal fistula in Chinese patients with Crohn disease.

The aim of this study was to (1) assess the independent factors affecting patients with postoperative intestinal fistula from Crohn disease (CD) by analyzing preoperative clinical data, (2) establish a nomogram prediction model for this condition based on these factors, and (3) validate this model and evaluate its accuracy. In this retrospective multicenter case-control study, the clinical data of 240 patients with CD admitted for surgical treatment between September 2019 and September 2021 at 3 centers were collected. Patients were randomly divided into a training set (168 patients) and a validation set (72 patients). Univariate analysis was performed for relevant factors, and statistically significant factors were then analyzed using multivariate logistic regression to determine the independent influencing factors. A nomogram model for predicting postoperative intestinal fistula in patients with CD was constructed and the accuracy of the model was evaluated using calibration curves. Univariate analysis showed that disease behavior, abdominal abscess, intestinal perforation, neutrophil-to-lymphocyte ratio, systemic immunoinflammatory index, and prognostic nutrition index were factors affecting postoperative intestinal fistula in patients with CD. Multivariate logistic regression analysis showed that neutrophil-to-lymphocyte ratio, prognostic nutrition index, disease behavior, and Crohn disease activity index score were independent influencing factors. After assessing the validation set, the area under the curve was 0.899, indicating good predictive accuracy of the nomogram model. The prediction model developed in this study can effectively predict the risk of postoperative intestinal fistula.

[The effectiveness of vacuum therapy and meglumine sodium succinate in unformed fistulas of the gastrointestinal tract (clinical observations)]. / Effektivnost' primeneniya vakuum-terapii i meglyumina natriya suktsinata pri nesformirovannykh svishchakh zheludochno-kishechnogo trakta (klinicheskie nablyudeniya).

The incidence of intestinal fistulas after laparotomy for various reasons (peritonitis, acute pancreatitis or trauma) is 1.5%. Fistula formation in patients with chronic gastrointestinal diseases has a rapid onset, severe course, and poor prognosis. Against the background of a long course of the disease and depletion of the body, there is a decrease in the activity of reparative processes, which leads to the manifestation of postoperative complications: the formation of fistulas, insolvency of intestinal anastomoses, peritonitis. Vacuum drainage is a treatment method aimed at eliminating exudate, reducing the area of the wound and its epithelization. The inclusion of a succinate-containing solution in the treatment regimen improves metabolic processes and improves the prognosis of the disease. As an illustration, a description of the clinical observation of patients with similar pathology and different treatment regimens is given.

Enteroatmospheric fistulas in open abdomen in trauma associated with abdominal reintervention and VAC therapy.

BACKGROUND: Open abdomen is an alternative for the management of trauma patient, and negative pressure therapy of the wound using VAC® device is a genuine sort of treatment. Although the device poses technical advantages, risks are present and a critical complication is the enteroatmospheric fistula formation (EAF). OBJECTIVE: To analize the role of negative pressure therapy length and VAC® device number of changes on the EAF formation in trauma patients udergoing open abdomen. METHOD: Cut-off points were calculated using receiver operational characteristics curve. Values were compared with Student's t or Mann-Withney U tests, considering statistically significant p < 0.05. RESULTS: EAF were present in 39 cases (5.9%). A significant difference in the presence of EAF was present in patients with negative pressure therapy of the wound length ≥ 11.2 days (46.9 vs. 1.3%; relative risk [RR]: 3.67; 95% confidence interval [95% IC]: 2.4-6.68; p = 0.017) and when ≥ 2.6 VAC® device changes were performed (34.6 vs. 0.5%; RR: 6.92; 95% IC: 1.1-4.3; p < 0.001). CONCLUSIONS: At our institution, the practice of >3 VAC® device changes and length of therapy > 11 days should be carefully considered leading to reduce the risk of EAF formation.

INTRODUCCIÓN: El abdomen abierto es una alternativa para manejar al paciente traumatizado, y una variante para instituirlo es la terapia de presión negativa de la herida con el dispositivo VAC®. Aunque tiene ventajas técnicas, no está exento de riesgos y una complicación crítica es la formación de fístulas enteroatmosféricas (FEA). OBJETIVO: Analizar el papel de la duración de la terapia de presión negativa y del número de cambios del dispositivo VAC® sobre la aparición de FEA en pacientes traumatizados manejados con abdomen abierto. MÉTODO: Se establecieron puntos de corte con curva de características operacionales del receptor. Los valores se compararon con la prueba t de Student o U de Mann-Whitney, considerando p < 0.05 como valor estadísticamente significativo. RESULTADOS: La FEA se presentó en 39 casos (5.9%). Hubo una diferencia significativa en la aparición de FEA en pacientes con duración de la terapia de presión negativa de la herida ≥ 11.2 días (46.9 vs 1.3%; riesgo relativo [RR]: 3.67; intervalo de confianza del 95% [IC95%]: 2.4-6.68; p = 0.017) y cuando se practicaron ≥ 2.6 cambios del dispositivo VAC® (34.6 vs. 0.5%; RR: 6.92; IC95%: 1.1-4.3; p < 0.001). CONCLUSIONES: En nuestra institución, la práctica de más de tres cambios del dispositivo VAC® y el mantenimiento de la terapia por más de 11 días debe ser cuidadosamente considerado para reducir el riesgo de formación de FEA.