Enterovaginal and colovesical fistulas as late complications of pelvic radiotherapy

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.

Radiation Enterocolitis Featuring the Perforation of the Sigmoid Colon, Small Bowel, and Entero-Colonic Fistula: A Case Report

Radiation enteritis poses a treatment challenge for patients undergoing or completing radiation therapy. A significant issue has been the patient's and surgeon's lack of awareness of the condition and the radiotherapy or associated surgical treatments. A 66-year-old female presented with acute onset of diffuse abdominal pain and peritonitis for one day, status post radiation therapy following a diagnosis of cervical cancer. A review of systems was positive for diffuse sweating, chills, and nausea. The patient was diagnosed with an entero-colonic fistula with mesenteric edema. An entero-colonic fistula due to radiation enterocolitis is a rare but important complication that can occur after radiation therapy for abdominal or pelvic malignancies. With any patient who has a history of abdominal or pelvic cancer and has received radiotherapy and shows up with acute abdomen, bowel perforation should be considered in the differential diagnosis with the possible management of acute complications.

Jejunocolic fistula presenting as chronic diarrhoea from advanced lymphoma

Jejunocolic fistula, a late complication of intestinal lymphoma, is a rare entity with only five reported cases in the literature. We report a young male presenting with a left lateral neck mass 5 years ago which then progressed to superior vena cava syndrome. Despite receiving radiotherapy and two cycles of chemotherapy, there was still tumour progression. He presented with a 2-week history of diarrhoea, haematochezia and weight loss for which antibiotics provided no relief. Esophagogastroduodenoscopy and colonoscopy showed a jejunocolic fistula. After discussion with the multidisciplinary team, nutritional upbuilding was initiated followed by exploratory laparotomy with segmental resection and anastomosis. On histopathology, diffuse large B-cell lymphoma involving the jejunum and colon was noted. Despite receiving palliative chemotherapy, he still succumbed to disease progression. This case highlights the importance of early recognition of jejunocolic fistulas among patients with intestinal lymphomas to facilitate early multidisciplinary intervention.

When the bowel meets the bladder: Optimal management of colorectal pathology with urological involvement

Fistulae between the gastrointestinal and urinary systems are rare but becoming increasingly more common in current surgical practice. They are a heterogeneous group of pathological entities that are uncommon complications of both benign and malignant processes. As the incidence of complicated diverticular disease and colorectal malignancy increases, so too does the extent of fistulous connections between the gastrointestinal and urinary systems. These complex problems will be more common as a factor of an aging population with increased life expectancy. Diverticular disease is the most commonly encountered aetiology, accounting for up to 80% of cases, followed by colorectal malignancy in up to 20%. A high index of suspicion is required in order to make the diagnosis, with ever improving imaging techniques playing an important role in the diagnostic algorithm. Management strategies vary, with most surgeons now advocating for a single-stage approach to enterovesical fistulae, particularly in the elective setting. Concomitant bladder management techniques are also disputed. Traditionally, open techniques were the standard; however, increased experience and advances in surgical technology have contributed to refined and improved laparoscopic management. Unfortunately, due to the relative rarity of these entities, no randomised studies have been performed to ascertain the most appropriate management strategy. Rectourinary fistulae have dramatically increased in incidence with advances in the non-operative management of prostate cancer. With radiotherapy being a major contributing factor in the development of these complex fistulae, optimum surgical approach and exposure has changed accordingly to optimise their management. Conservative management in the form of diversion therapy is effective in temporising the situation and allowing for the diversion of faecal contents if there is associated soiling, macerated tissues or associated co-morbidities. One may plan for definitive surgical intervention at a later stage. Less contaminated cases with no fibrosis may proceed directly to definitive surgery if the appropriate expertise is available. An abdominal approach with direct repair and omentum interposition between the repaired tissues has been well described. In low lying fistulae, a transperineal approach with the patient in a prone-jack knife position provides optimum exposure and allows for the use of interposition muscle grafts. According to recent literature, it offers a high success rate in complex cases.

Enterocutaneous Fistula: A Simplified Clinical Approach

A “fistula” is an abnormal connection between two epithelial surfaces. Fistulae are named based on the two surfaces or lumens they connect to. Fistulae form due to loss of wall integrity from an underlying insult, leading to the penetrance of an adjacent organ or epithelized surface. Common causes of small bowel fistulae include sequelae of surgical intervention, foreign body, bowel diverticula, Crohn's disease, malignancy, radiation, and infection. A histopathological analysis displays acute and/or chronic inflammation due to the underlying pathology.

A thorough history and physical examination are important components of patient evaluation. Generally, patients will present with non-specific constitutional symptoms in addition to local symptoms attributed to the fistula. In rare instances, symptoms may be severe and life-threatening. Initial laboratory workup includes complete blood count, comprehensive metabolic panel, and lactate level. Radiologic imaging is useful for definitive diagnosis and helps delineate anatomy. In practice, computed tomography (CT) is the initial imaging modality. The addition of intravenous or enteric contrast may be helpful in certain situations. Magnetic resonance imaging (MRI) may also be used in special circumstances. Invasive procedures, such as endoscopy, can assist in the evaluation of mucosal surfaces to diagnose pathology such as inflammatory processes.

Appropriate management should include optimizing nutritional status, delineating fistulous tract anatomy, skincare, and managing the underlying disease. A non-operative approach is generally accepted as the initial approach especially in the acute/subacute setting. However, operative intervention is indicated in the setting of failed non-operative management. Successful management of small bowel fistulae requires a multidisciplinary team approach.

To conclude, a small bowel fistula is a complex clinical disease, with surgical intervention being the most common cause in developed countries. The non-operative approach should be trialed before an operative approach is considered.