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Aras OA, Patel AS, Satchell EK, Serniak NJ, Byrne RM, Cagir B. Comparison of outcomes in small bowel surgery for Crohn's disease: a retrospective NSQIP review. Int J Colorectal Dis 2024; 39:119. [PMID: 39073495 PMCID: PMC11286688 DOI: 10.1007/s00384-024-04661-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/28/2024] [Indexed: 07/30/2024]
Abstract
INTRODUCTION Despite advances in medical therapy, approximately 33% of Crohn's disease (CD) patients will need surgery within 5 years after initial diagnosis. Several surgical approaches to CD have been proposed including small bowel resection, strictureplasty, and combined surgery with resection plus strictureplasty. Here, we utilize the American College of Surgeons (ACS) national surgical quality registry (NSQIP) to perform a comprehensive analysis of 30-day outcomes between these three surgical approaches for CD. METHODS The authors queried the ACS-NSQIP database between 2015 and 2020 for all patients undergoing open or laparoscopic resection of small bowel or strictureplasty for CD using CPT and IC-CM 10. Outcomes of interest included length of stay, discharge disposition, wound complications, 30-day related readmission, and reoperation. RESULTS A total of 2578 patients were identified; 87% of patients underwent small bowel resection, 5% resection with strictureplasty, and 8% strictureplasty alone. Resection plus strictureplasty (combined surgery) was associated with the longest operative time (p = 0.002). Patients undergoing small bowel resection had the longest length of hospital stay (p = 0.030) and the highest incidence of superficial/deep wound infection (44%, p = 0.003) as well as the highest incidence of sepsis (3.5%, p = 0.03). Small bowel resection was found to be associated with higher odds of wound complication compared to combined surgery (OR 2.09, p = 0.024) and strictureplasty (1.9, p = 0.005). CONCLUSION Our study shows that various surgical approaches for CD are associated with comparable outcomes in 30-day related reoperation and readmission, or disposition following surgery between all three surgical approaches. However, small bowel resection displayed higher odds of developing post-operative wound complications.
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Affiliation(s)
- Oguz Az Aras
- Department of Surgery, Guthrie Clinic, Guthrie Robert Packer Hospital, 1 Guthrie Square, Sayre, PA, 18840, USA.
- Department of Internal Medicine, TriStar Centennial Medical Center, Nashville, TN, USA.
| | - Apar S Patel
- Department of Surgery, Guthrie Clinic, Guthrie Robert Packer Hospital, 1 Guthrie Square, Sayre, PA, 18840, USA
- Department of Surgery, Geisinger Health System, Danville, PA, USA
| | - Emma K Satchell
- Department of Surgery, Guthrie Clinic, Guthrie Robert Packer Hospital, 1 Guthrie Square, Sayre, PA, 18840, USA
| | - Nicholas J Serniak
- Department of Surgery, Guthrie Clinic, Guthrie Robert Packer Hospital, 1 Guthrie Square, Sayre, PA, 18840, USA
| | - Raphael M Byrne
- Department of Surgery, Guthrie Clinic, Guthrie Robert Packer Hospital, 1 Guthrie Square, Sayre, PA, 18840, USA
| | - Burt Cagir
- Department of Surgery, Guthrie Clinic, Guthrie Robert Packer Hospital, 1 Guthrie Square, Sayre, PA, 18840, USA
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Shbaita S, Daraghmeh L, Abu Saleem N, Rostom A, Abdoh Q, Maqboul I. Management of Enterocutaneous Fistula in Crohn's Disease by Embolization With Glue Injection and Coiling: A Case Report. Cureus 2023; 15:e43089. [PMID: 37680418 PMCID: PMC10482355 DOI: 10.7759/cureus.43089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2023] [Indexed: 09/09/2023] Open
Abstract
There is one reported case of a pancreatoduodenal fistula that was managed using combined coil embolization and fibrin glue after the failure of other methods. Herein, we document this case to highlight the value of coil embolization and fibrin glue as surgical alternatives for fistula treatment. We present a case of a 39-year-old female patient who has a known case of Crohn's disease (CD) and presented with an enterocutaneous fistula (ECF) after her most recent surgery. With the failure of conservative approaches and as she refused any surgical interventions, fibrin glue injection and coiling were used. As a conclusion, embolization may work well as a surgical management alternative due to its simplicity.
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Affiliation(s)
- Sara Shbaita
- Faculty of Medicine, An-Najah National University, Nablus, PSE
| | - Laith Daraghmeh
- General Surgery, An-Najah National University Hospital, Nablus, PSE
| | - Nael Abu Saleem
- Radiology, An-Najah National University Hospital, Nablus, PSE
| | - Alaa Rostom
- General Surgery, An-Najah National University Hospital, Nablus, PSE
| | - Qusay Abdoh
- Gastroenterology and Hepatology, An-Najah National University Hospital, Nablus, PSE
| | - Iyad Maqboul
- General Surgery, An-Najah National University Hospital, Nablus, PSE
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3
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Barreiro-de Acosta M, Riestra S, Calafat M, Soto MP, Calvo M, Sánchez Rodríguez E, Caballol B, Vela M, Rivero M, Muñoz F, de Castro L, Calvet X, García-Alonso FJ, Utrilla Fornals A, Ferreiro-Iglesias R, González-Muñoza C, Chaparro M, Bujanda L, Sicilia B, Alfambra E, Rodríguez A, Pérez Fernández R, Rodríguez C, Almela P, Argüelles F, Busquets D, Tamarit-Sebastián S, Reygosa Castro C, Jiménez L, Marín-Jiménez I, Alcaide N, Fernández-Salgado E, Iglesias Á, Ponferrada Á, Pajares R, Roncero Ó, Morales-Alvarado VJ, Ispízua-Madariaga N, Sáinz E, Merino O, Márquez-Mosquera L, García-Sepulcre M, Elorza A, Estrecha S, Surís G, Van Domselaar M, Brotons A, de Francisco R, Cañete F, Iglesias E, Vera MI, Mesonero F, Lorente R, Zabana Y, Cabriada JL, Domènech E, Rodríguez-Lago I. Management and Long-term Outcomes of Crohn's Disease Complicated with Enterocutaneous Fistula: ECUFIT Study from GETECCU. J Crohns Colitis 2022; 16:1049-1058. [PMID: 35104314 DOI: 10.1093/ecco-jcc/jjac016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 01/10/2022] [Accepted: 01/25/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Crohn's disease [CD] can develop penetrating complications at any time during the disease course. Enterocutaneous fistulae [ECF] are disease-related complications with an important impact on quality of life. Our aim was to describe the outcomes of this complication, including its medical and/or surgical management and their temporal trends. The primary endpoint was fistula closure, defined as the absence of drainage, with no new abscess or surgery, over the preceding 6 months. METHODS Clinical information from all adult patients with CD and at least one ECF-excluding perianal fistulae-were identified from the prospectively-maintained ENEIDA registry. All additional information regarding treatment for this complication was retrospectively reviewed. RESULTS A total of 301 ECF in 286 patients [January 1970-September 2020] were analysed out of 30 088 records. These lesions were mostly located in the ileum [67%] and they had a median of one external opening [range 1-10]. After a median follow-up of 146 months (interquartile range [IQR], 69-233), 69% of patients underwent surgery. Fistula closure was achieved in 84%, mostly after surgery, and fistula recurrence was uncommon [13%]. Spontaneous and low-output fistulae were associated with higher closure rates (hazard ratio [HR] 1.51, 95% confidence interval [CI] 1.17-1.93, p = 0.001, and HR 1.49, 95% CI 1.07-2.06, p = 0.03, respectively); this was obtained more frequently with medical therapy since biologics have been available. CONCLUSIONS ECF complicating CD are rare but entail a high burden of medical and surgical resources. Closure rates are high, usually after surgery, and fistula recurrence is uncommon. A significant proportion of patients receiving medical therapy can achieve fistula closure.
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Affiliation(s)
- Manuel Barreiro-de Acosta
- Gastroenterology Department, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain
| | - Sabino Riestra
- Gastroenterology Department, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
| | - Margalida Calafat
- Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas CIBERehd, Madrid, Spain
| | - María Pilar Soto
- Gastroenterology Department, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Marta Calvo
- Gastroenterology Department, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
| | | | - Berta Caballol
- Gastroenterology Department, Hospital Clinic, Barcelona, Spain
| | - Milagros Vela
- Gastroenterology Department, Hospital Universitario Nuestra Señora de Candelaria, Santa Cruz de Tenerife, Spain
| | - Montserrat Rivero
- Gastroenterology Department, Hospital Universitario Marqués de Valdecilla and IDIVAL, Santander, Spain
| | - Fernando Muñoz
- Gastroenterology Department, Hospital Universitario de Salamanca, Salamanca, Spain
| | - Luisa de Castro
- Gastroenterology Department, Hospital Álvaro Cunqueiro, Vigo, Spain
| | - Xavier Calvet
- Gastroenterology Department, Corporació Parc Taulí, Sabadell, and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas CIBERehd, Madrid, Spain
| | | | | | - Rocío Ferreiro-Iglesias
- Gastroenterology Department, Hospital Clínico Universitario de Santiago, Santiago de Compostela, Spain
| | | | - María Chaparro
- Gastroenterology Department, Hospital Universitario de La Princesa, Instituto de Investigación Sanitaria Princesa IIS-IP, and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas CIBERehd, Madrid, Spain
| | - Luis Bujanda
- Gastroenterology Department, Biodonostia Health Research Institute, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas [CIBERehd], and Universidad del País Vasco [UPV/EHU], San Sebastián, Spain
| | - Beatriz Sicilia
- Gastroenterology Department, Hospital Universitario de Burgos, Burgos, Spain
| | - Erika Alfambra
- Gastroenterology Department, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
| | - Andrés Rodríguez
- Gastroenterology Department, Hospital General Universitario de Alicante, Alicante, Spain
| | - Rubén Pérez Fernández
- Gastroenterology Department, Complejo Asistencial Universitario de León, León, Spain
| | - Cristina Rodríguez
- Gastroenterology Department, Complejo Hospitalario de Navarra, Pamplona, Spain
| | - Pedro Almela
- Gastroenterology Department, Hospital General Universitari de Castelló, Castelló, Spain
| | - Federico Argüelles
- Gastroenterology Department, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - David Busquets
- Gastroenterology Department, Hospital Universitari Girona Dr. Josep Trueta, Girona, Spain
| | | | - Cristina Reygosa Castro
- Gastroenterology Department, Complejo Hospitalario Universitario de Canarias, San Cristóbal de La Laguna, Spain
| | - Laura Jiménez
- Gastroenterology Department, Hospital Universitario de Fuenlabrada, Fuenlabrada, Spain
| | - Ignacio Marín-Jiménez
- Gastroenterology Department, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Noelia Alcaide
- Gastroenterology Department, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Estela Fernández-Salgado
- Gastroenterology Department, Complejo Hospitalario Universitario de Pontevedra, Pontevedra, Spain
| | - Águeda Iglesias
- Gastroenterology Department, Complexo Hospitalario Universitario de Ourense, Ourense, Spain
| | - Ángel Ponferrada
- Gastroenterology Department, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - Ramón Pajares
- Gastroenterology Department, Hospital Universitario Infanta Sofía, San Sebastián de los Reyes, Spain
| | - Óscar Roncero
- Gastroenterology Department, Hospital General La Mancha Centro, Alcázar de San Juan, Spain
| | | | | | - Empar Sáinz
- Gastroenterology Department, Xarxa Assistencial Universitària de Manresa, Manresa, Spain
| | - Olga Merino
- Gastroenterology Department, Hospital Universitario de Cruces, Barakaldo, Spain
| | | | | | - Ainara Elorza
- Gastroenterology Department, Hospital Universitario de Galdakao, Biocruces Bizkaia Health Research Institute, Galdakao, Spain
| | - Sandra Estrecha
- Gastroenterology Department, Hospital Universitario Araba, Vitoria, Spain
| | - Gerard Surís
- Gastroenterology Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Spain
| | - Manuel Van Domselaar
- Gastroenterology Department, Hospital Universitario de Torrejón, Torrejón de Ardoz, Spain
| | - Alicia Brotons
- Gastroenterology Department, Hospital Vega Baja, Orihuela, Spain
| | - Ruth de Francisco
- Gastroenterology Department, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias, Oviedo, Spain
| | - Fiorella Cañete
- Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas CIBERehd, Madrid, Spain
| | - Eva Iglesias
- Gastroenterology Department, Hospital Universitario Reina Sofía, Córdoba, Spain
| | - María Isabel Vera
- Gastroenterology Department, Hospital Universitario Puerta de Hierro, Majadahonda, Spain
| | - Francisco Mesonero
- Gastroenterology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Rufo Lorente
- Gastroenterology Department, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain
| | - Yamile Zabana
- Gastroenterology Department, Hospital Universitari Mútua Terrassa, Terrassa, and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas CIBERehd, Madrid, Spain
| | - José Luis Cabriada
- Gastroenterology Department, Hospital Universitario de Galdakao, Biocruces Bizkaia Health Research Institute, Galdakao, Spain
| | - Eugeni Domènech
- Gastroenterology Department, Hospital Universitari Germans Trias i Pujol, Badalona, and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas CIBERehd, Madrid, Spain
| | - Iago Rodríguez-Lago
- Gastroenterology Department, Hospital Universitario de Galdakao, Biocruces Bizkaia Health Research Institute, Galdakao, Spain
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Luceri C, D’Ambrosio M, Bigagli E, Cinci L, Russo E, Staderini F, Cricchio M, Giudici F, Scaringi S. Involvement of MIR-126 and MMP9 in the Pathogenesis of Intra-Abdominal Fistulizing Crohn’s Disease: A Brief Research Report. Front Surg 2022; 9:822407. [PMID: 35620197 PMCID: PMC9127299 DOI: 10.3389/fsurg.2022.822407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 04/22/2022] [Indexed: 11/15/2022] Open
Abstract
Background Intra-abdominal fistulas are complications that affect a significant proportion of Crohn’s disease patients, often requiring surgery. The aim of the present work was to correlate the occurrence of intestinal fistulization to the clinico-pathological features of these patients and to the plasma levels of MMP9, a gelatinase involved in the pathophysiology of fistula formation, and of miR-126, appearing to modulate MMP9 expression. Methods In a series of 31 consecutive Crohn’s patients admitted to surgery due to therapeutic failure and/or complicated disease, we identified nine cases of abdominal fistulas, mainly entero-enteric fistulas. MMP9 protein was determined in plasma and at the intestinal level using immunometric assays. Circulating miR-126 was also measured in all plasma samples by real-time PCR. Results Comparing patients with and without intra-abdominal fistulas, we did not observe differences in terms of age, gender, disease location and duration, number of previous surgeries and pre-biologic medications. However, cases with intra-abdominal fistulas had a significantly higher CDAI (p < 0.0001) and a significantly lower circulating miR-126 (p < 0.05). Patients with intra-abdominal fistulas had also a significantly higher amount of circulating MMP9 (p < 0.0001) and this data was correlated with an increased expression of MMP9 protein in the mucosa and with reduced levels of circulating miR-126. Receiver operating characteristic (ROC) analysis pointed out the ability of circulating MMP9 to discriminate patients with and without intra-abdominal fistulas. Conclusions These data confirm that circulating MMP9 can be used for the identification of cases with intra-abdominal fistulas and suggest that miR-126 may be also involved in the pathogenesis of this complication and that it may be further investigated as a new therapeutic strategy or for monitoring therapeutic response in these patients.
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Affiliation(s)
- Cristina Luceri
- Department of Neuroscience, Psychology, Drug Research and Child Health - NEUROFARBA, Section of Pharmacology and Toxicology, University of Florence, Florence, Italy
| | - Mario D’Ambrosio
- Department of Neuroscience, Psychology, Drug Research and Child Health - NEUROFARBA, Section of Pharmacology and Toxicology, University of Florence, Florence, Italy
| | - Elisabetta Bigagli
- Department of Neuroscience, Psychology, Drug Research and Child Health - NEUROFARBA, Section of Pharmacology and Toxicology, University of Florence, Florence, Italy
| | - Lorenzo Cinci
- Department of Neuroscience, Psychology, Drug Research and Child Health - NEUROFARBA, Section of Pharmacology and Toxicology, University of Florence, Florence, Italy
| | - Edda Russo
- Department of Surgery and Translational Medicine, Section of Surgery, University of Florence, Florence, Italy
- Surgical Unit, Careggi Teaching Hospital, Florence, Italy
| | - Fabio Staderini
- Department of Surgery and Translational Medicine, Section of Surgery, University of Florence, Florence, Italy
- Surgical Unit, Careggi Teaching Hospital, Florence, Italy
| | - Marta Cricchio
- Department of Surgery and Translational Medicine, Section of Surgery, University of Florence, Florence, Italy
- Surgical Unit, Careggi Teaching Hospital, Florence, Italy
| | - Francesco Giudici
- Department of Surgery and Translational Medicine, Section of Surgery, University of Florence, Florence, Italy
- Surgical Unit, Careggi Teaching Hospital, Florence, Italy
- Correspondence: Francesco Giudici
| | - Stefano Scaringi
- Department of Surgery and Translational Medicine, Section of Surgery, University of Florence, Florence, Italy
- Surgical Unit, Careggi Teaching Hospital, Florence, Italy
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Abstract
BACKGROUND Management of enterocutaneous fistulas in Crohn's disease is challenging. Most patients still need intestinal resection in the biologic era. OBJECTIVE The aim of this study was to evaluate the efficacy of endoscopic treatment for enterocutaneous fistulas. DESIGN This is a retrospective study of medical records. SETTINGS This study was conducted in a single institution. PATIENTS All consecutive patients with Crohn's disease with an enterocutaneous fistula who underwent endoscopic fistula closure with the use of an over-the-scope clip or a hemostatic clip were included. MAIN OUTCOME MEASURES The main outcome measured was the clinical success 3 months after the procedure, which was defined as the complete closure of all fistulas at physical examination and complete cessation of the drainage from the external opening, without surgery. RESULTS Eight patients (men, 25%; median age 45 years [interquartile range, 33-51]) were followed. Fistulas were localized at the ileocolonic or colocolonic anastomosis in 7 patients and at the stomach in 1 patient. Seven patients were treated with an over-the-scope clip, and one was treated with a hemostatic clip. Technical success was achieved in all cases. Clinical success at 3 months was achieved in 75% of cases (6/8 patients). After a median 16-month (interquartile range, 13-23) follow-up, 3 of 8 (37.5%) patients had enterocutaneous fistula closure and 2 of 8 (25%) needed intestinal resection. No complications were observed. LIMITATIONS The retrospective nature, the small sample size of the study, and the heterogeneity of the population limit the interpretation of the results. CONCLUSIONS Endoscopic treatment of enterocutaneous fistulas is feasible with a short-term effectiveness. Additional studies are needed to confirm these results. See Video Abstract at http://links.lww.com/DCR/B614. TRATAMIENTO ENDOSCPICO DE FSTULAS ENTEROCUTNEAS EN ENFERMEDAD DE CROHN ANTECEDENTES:Es desafiante el manejo de las fístulas enterocutáneas en enfermedad de Crohn. En la era biológica, la mayoría de los pacientes todavía requieren de resección intestinal.OBJETIVO:Evaluar la eficacia por tratamiento endoscópico de fístulas enterocutáneas.ENTORNO CLINICO:Estudio retrospectivo de registros médicos.AJUSTE:Realizado en una sola institución.PACIENTES:Se incluyeron todos los pacientes consecutivos con fístula enterocutánea en enfermedad de Crohn, sometidos a cierre endoscópico de la fístula con clip sobre el endoscopio o clip hemostático.PRINCIPALES MEDIDAS DE VALORACION:El éxito clínico a los 3 meses después del procedimiento. Definido al examen físico, como el cierre completo de todas las fístulas y cese completo del drenaje por la abertura externa, sin cirugía.RESULTADOS:Se estudiaron a ocho pacientes (hombres, 25%, mediana de edad de 45 años (rango intercuartílico, 33-51)). En 7 pacientes, las fístulas se localizaron en la anastomosis ileocolónica o colocolónica y un paciente, en el estómago. Siete pacientes fueron tratados con clip sobre el endoscopio y uno con clip hemostático. Se logró éxito técnico en todos los casos. Se logró éxito clínico a los 3 meses en 75% de los casos (6/8 pacientes). Después de una mediana de 16 meses (rango intercuartílico, 13-23), de seguimiento 3/8 (37,5%) pacientes presentaron cierre de fístulas enterocutáneas y 2/8 (25%) requirieron resección intestinal. No se observaron complicaciones.LIMITACIONES:Estudio retrospectivo, pequeño tamaño de la muestra y heterogeneidad de la población, limitaron la interpretación de los resultados.CONCLUSIONES:Es posible el tratamiento endoscópico de fístulas enterocutáneas con efectividad a corto plazo. Se requieren nuevos estudios para confirmar estos resultados. Consulte Video Resumen en http://links.lww.com/DCR/B614. (Traducción-Dr. Fidel Ruiz Healy).
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Can Enteric Fistulae in Patients with Crohn's Disease Occur in Isolation: Findings from 500 Consecutive Operative Cases. J Gastrointest Surg 2022; 26:643-651. [PMID: 34845653 DOI: 10.1007/s11605-021-05199-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 10/26/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND OR PURPOSE Enteric Crohn's disease (CD) is characterized by transmural inflammation resulting in inflammatory, stricturing, or penetrating phenotypes. However, data regarding the relationship between stricturing and penetrating behavior is lacking. The incidence of penetrating CD in the absence of a stricture is unclear. The aim of this study is to assess if enteric fistulae in adult patients undergoing abdominal surgery for symptomatic CD occur in isolation. METHODS Resection or repair of enteric CD fistulae performed in a quaternary care referral center (2009-2017) was analyzed. Fistulae associated with pelvic or continent pouch, rectal stump, or ano-vagina were excluded. Fistulae were stratified based on origin, tract, target, and relationship to stricture. Strictures were stratified as inflammatory or fibrostenotic. RESULTS Five hundred consecutive operative reports were reviewed. A total of 490 fistulae were evaluated. Two hundred ninety-nine fistulae were in patients undergoing index surgery. Incidence of CD fistulae not associated with stricture was 14.9% in total, but only 8% in the index surgery cohort. The majority of fistulae originated from the ileum (95%). CD fistulae originating from the stomach or duodenum were not identified in the index cohort. Fistulae within an inflammatory stricture were likely to include an intra-abdominal abscess (p < 0.001). Fistulae associated with a fibrostenotic stricture were more likely to originate proximal to the stricture (p < 0.001). The incidence of fistula-associated adenocarcinoma was 0.6%. CONCLUSIONS Symptomatic CD fistulae in the absence of stricture are uncommon. Caution should be exercised when making a diagnosis of CD in the presence of enteric fistulae, but an absence of stricture, particularly in patients with prior abdominal surgery.
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Assaker R, El Hasbani G, Amoateng D, Vargas J, Nepal P, Armm M. Complex vesicocutaneous fistula: Successful conservative management. Urol Case Rep 2021; 38:101741. [PMID: 34168962 PMCID: PMC8207227 DOI: 10.1016/j.eucr.2021.101741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 05/27/2021] [Accepted: 06/01/2021] [Indexed: 11/03/2022] Open
Abstract
Vesicocutaneous fistulas are rare entities that could be either congenital or acquired. The diagnosis is usually based on clinical findings and imaging modalities. While most vesicocutaneous fistulas heal spontaneously, it is important to decrease the intravesicular pressure by diverting the urine. Moreover, surgical options are present to remove the fistula. In this case report, we highlight the case of a 67-year-old male, with recurrent obstructive cystitis and colorectal adenocarcinoma who developed a vesicocutaneous fistula. Decompression of the bladder led to complete closure of the tract.
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Affiliation(s)
| | - Georges El Hasbani
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | | | - Jose Vargas
- St. Vincent's Medical Center, Bridgeport, CT, USA
| | - Pankaj Nepal
- St. Vincent's Medical Center, Bridgeport, CT, USA
| | - Milton Armm
- St. Vincent's Medical Center, Bridgeport, CT, USA
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8
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Lightner AL, Ashburn JH, Brar MS, Carvello M, Chandrasinghe P, van Overstraeten ADB, Fleshner PR, Gallo G, Kotze PG, Holubar SD, Reza LM, Spinelli A, Strong SA, Tozer PJ, Truong A, Warusavitarne J, Yamamoto T, Zaghiyan K. Fistulizing Crohn's disease. Curr Probl Surg 2020; 57:100808. [PMID: 33187597 DOI: 10.1016/j.cpsurg.2020.100808] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 04/22/2020] [Indexed: 02/06/2023]
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9
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The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Surgical Management of Crohn's Disease. Dis Colon Rectum 2020; 63:1028-1052. [PMID: 32692069 DOI: 10.1097/dcr.0000000000001716] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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10
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Pellino G, Keller DS, Sampietro GM, Angriman I, Carvello M, Celentano V, Colombo F, Di Candido F, Laureti S, Luglio G, Poggioli G, Rottoli M, Scaringi S, Sciaudone G, Sica G, Sofo L, Leone S, Danese S, Spinelli A, Delaini G, Selvaggi F. Inflammatory bowel disease position statement of the Italian Society of Colorectal Surgery (SICCR): Crohn's disease. Tech Coloproctol 2020; 24:421-448. [PMID: 32172396 DOI: 10.1007/s10151-020-02183-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 02/24/2020] [Indexed: 02/07/2023]
Abstract
The Italian Society of Colorectal Surgery (SICCR) promoted the project reported here, which consists of a position statement of Italian colorectal surgeons to address the surgical aspects of Crohn's disease management. Members of the society were invited to express their opinions on several items proposed by the writing committee, based on evidence available in the literature. The results are presented, focusing on relevant points. The present paper is not an alternative to available guidelines; rather, it offers a snapshot of the attitudes of SICCR surgeons about the surgical treatment of Crohn's disease. The committee was able to identify some points of major disagreement and suggested strategies to improve quality of available data and acceptance of guidelines.
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Affiliation(s)
- G Pellino
- Colorectal Surgery, Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Policlinico CS, Piazza Miraglia 2, 80138, Naples, Italy.
| | - D S Keller
- Division of Colon and Rectal Surgery, Department of Surgery, New York-Presbyterian, Columbia University Medical Center, New York, NY, USA
| | | | - I Angriman
- General Surgery Unit, Azienda Ospedaliera di Padova, Padua, Italy
| | - M Carvello
- Colon and Rectal Surgery Division, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - V Celentano
- Portsmouth Hospitals NHS Trust, University of Portsmouth, Portsmouth, UK
| | - F Colombo
- L. Sacco University Hospital, Milan, Italy
| | - F Di Candido
- Colon and Rectal Surgery Division, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - S Laureti
- Surgery of the Alimentary Tract, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - G Luglio
- Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - G Poggioli
- Surgery of the Alimentary Tract, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - M Rottoli
- Surgery of the Alimentary Tract, Department of Medical and Surgical Sciences, Sant'Orsola Hospital, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - S Scaringi
- Surgical Unit, Department of Surgery and Translational Medicine, University of Firenze, Florence, Italy
| | - G Sciaudone
- Colorectal Surgery, Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Policlinico CS, Piazza Miraglia 2, 80138, Naples, Italy
| | - G Sica
- Minimally Invasive and Gastro-Intestinal Unit, Department of Surgery, Policlinico Tor Vergata, Rome, Italy
| | - L Sofo
- Abdominal Surgery Department, Fondazione Policlinico Universitario A. Gemelli IRCCS, Catholic University of Rome, Rome, Italy
| | - S Leone
- CEO, Associazione nazionale per le Malattie Infiammatorie Croniche dell'Intestino "A.M.I.C.I. Onlus", Milan, Italy
| | - S Danese
- Division of Gastroenterology, IBD Center, Humanitas University, Rozzano, Milan, Italy
| | - A Spinelli
- Colon and Rectal Surgery Division, Humanitas Clinical and Research Center, Rozzano, Milan, Italy
| | - G Delaini
- Department of Surgery, "Pederzoli" Hospital, Peschiera del Garda, Verona, Italy
| | - F Selvaggi
- Colorectal Surgery, Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Policlinico CS, Piazza Miraglia 2, 80138, Naples, Italy
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11
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Brown SR, Fearnhead NS, Faiz OD, Abercrombie JF, Acheson AG, Arnott RG, Clark SK, Clifford S, Davies RJ, Davies MM, Douie WJP, Dunlop MG, Epstein JC, Evans MD, George BD, Guy RJ, Hargest R, Hawthorne AB, Hill J, Hughes GW, Limdi JK, Maxwell-Armstrong CA, O'Connell PR, Pinkney TD, Pipe J, Sagar PM, Singh B, Soop M, Terry H, Torkington J, Verjee A, Walsh CJ, Warusavitarne JH, Williams AB, Williams GL, Wilson RG. The Association of Coloproctology of Great Britain and Ireland consensus guidelines in surgery for inflammatory bowel disease. Colorectal Dis 2018; 20 Suppl 8:3-117. [PMID: 30508274 DOI: 10.1111/codi.14448] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 09/17/2018] [Indexed: 12/14/2022]
Abstract
AIM There is a requirement of an expansive and up to date review of surgical management of inflammatory bowel disease (IBD) that can dovetail with the medical guidelines produced by the British Society of Gastroenterology. METHODS Surgeons who are members of the ACPGBI with a recognised interest in IBD were invited to contribute various sections of the guidelines. They were directed to produce a procedure based document using literature searches that were systematic, comprehensible, transparent and reproducible. Levels of evidence were graded. An editorial board was convened to ensure consistency of style, presentation and quality. Each author was asked to provide a set of recommendations which were evidence based and unambiguous. These recommendations were submitted to the whole guideline group and scored. They were then refined and submitted to a second vote. Only those that achieved >80% consensus at level 5 (strongly agree) or level 4 (agree) after 2 votes were included in the guidelines. RESULTS All aspects of surgical care for IBD have been included along with 157 recommendations for management. CONCLUSION These guidelines provide an up to date and evidence based summary of the current surgical knowledge in the management of IBD and will serve as a useful practical text for clinicians performing this type of surgery.
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Affiliation(s)
- S R Brown
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - N S Fearnhead
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - O D Faiz
- St Mark's Hospital, Middlesex, Harrow, UK
| | | | - A G Acheson
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - R G Arnott
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - S K Clark
- St Mark's Hospital, Middlesex, Harrow, UK
| | | | - R J Davies
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - M M Davies
- University Hospital of Wales, Cardiff, UK
| | - W J P Douie
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | - J C Epstein
- Salford Royal NHS Foundation Trust, Salford, UK
| | - M D Evans
- Morriston Hospital, Morriston, Swansea, UK
| | - B D George
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - R J Guy
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - R Hargest
- University Hospital of Wales, Cardiff, UK
| | | | - J Hill
- Manchester Foundation Trust, Manchester, UK
| | - G W Hughes
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - J K Limdi
- The Pennine Acute Hospitals NHS Trust, Manchester, UK
| | | | | | - T D Pinkney
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - J Pipe
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - P M Sagar
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - B Singh
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - M Soop
- Salford Royal NHS Foundation Trust, Salford, UK
| | - H Terry
- Crohn's and Colitis UK, St Albans, UK
| | | | - A Verjee
- Patient Liaison Group, Association of Coloproctology of Great Britain and Ireland, Royal College of Surgeons of England, London, UK
| | - C J Walsh
- Wirral University Teaching Hospital NHS Foundation Trust, Arrowe Park Hospital, Upton, UK
| | | | - A B Williams
- Guy's and St Thomas' NHS Foundation Trust, London, UK
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12
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Abstract
Crohn's disease (CD) leads to the development of complications through progressive uncontrolled inflammation and the transmural involvement of the bowel wall. Most of the available literature on penetrating CD focuses on the perianal phenotype. The management of nonperianal penetrating complications poses its own set of challenges and can result in significant morbidity and an increased risk of mortality. Few controlled trials have been published evaluating this subgroup of patients for clinicians to use for guidance. Utilizing the available evidence, we review the epidemiology, presentation, and modalities used to diagnosis and assess intestinal fistulas, phlegmons, and abscesses. The literature regarding the medical, endoscopic, and surgical management options are reviewed providing physicians with a therapeutic framework to comprehensively treat these nonperianal penetrating complications. Through a multidisciplinary evidence-based approach to the complex sequela of CD outcomes can be improved and patient's quality of life enhanced.10.1093/ibd/izx108_video1izx108_Video5754037501001.
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Affiliation(s)
- Robert P Hirten
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Shailja Shah
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - David B Sachar
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Jean-Frederic Colombel
- The Dr. Henry D. Janowitz Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
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13
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Toh JWT, Stewart P, Rickard MJFX, Leong R, Wang N, Young CJ. Indications and surgical options for small bowel, large bowel and perianal Crohn's disease. World J Gastroenterol 2016; 22:8892-8904. [PMID: 27833380 PMCID: PMC5083794 DOI: 10.3748/wjg.v22.i40.8892] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 08/26/2016] [Accepted: 09/28/2016] [Indexed: 02/06/2023] Open
Abstract
Despite advancements in medical therapy of Crohn's disease (CD), majority of patients with CD will eventually require surgical intervention, with at least a third of patients requiring multiple surgeries. It is important to understand the role and timing of surgery, with the goals of therapy to reduce the need for surgery without increasing the odds of emergency surgery and its associated morbidity, as well as to limit surgical recurrence and avoid intestinal failure. The profile of CD patients requiring surgical intervention has changed over the decades with improvements in medical therapy with immunomodulators and biological agents. The most common indication for surgery is obstruction from stricturing disease, followed by abscesses and fistulae. The risk of gastrointestinal bleeding in CD is high but the likelihood of needing surgery for bleeding is low. Most major gastrointestinal bleeding episodes resolve spontaneously, albeit the risk of re-bleeding is high. The risk of colorectal cancer associated with CD is low. While current surgical guidelines recommend a total proctocolectomy for colorectal cancer associated with CD, subtotal colectomy or segmental colectomy with endoscopic surveillance may be a reasonable option. Approximately 20%-40% of CD patients will need perianal surgery during their lifetime. This review assesses the practice parameters and guidelines in the surgical management of CD, with a focus on the indications for surgery in CD (and when not to operate), and a critical evaluation of the timing and surgical options available to improve outcomes and reduce recurrence rates.
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14
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Daldoul S. [Spontaneous cutaneous fistula of hydatid liver cysts]. Ann Dermatol Venereol 2015; 142:736-41. [PMID: 26563822 DOI: 10.1016/j.annder.2015.10.580] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 07/09/2015] [Accepted: 10/02/2015] [Indexed: 11/15/2022]
Abstract
BACKGROUND Spontaneous cutaneous fistula of hydatid liver cysts is a rare complication. Its genesis involves anatomic factors as well as other local factors. AIMS An exhaustive literature review was conducted to identify the characteristics of this complication, treatment modalities and the results obtained. PATIENTS AND METHODS An exhaustive bibliographic search was made for all articles published in French and English relating to parietal complications of hydatid liver cyst, from which we retained only those involving cases of cutaneous cyst fistulas (communicating rupture), to which we added our own case. RESULTS Seventeen cases of cystocutaneous fistula have been reported. The reason for consultation was productive cutaneous fistula. Morphological investigations were highly evocative of the diagnosis. Thirteen patients were treated by surgery, two underwent percutaneous debridement, and two declined treatment. DISCUSSION Cutaneous fistula constitutes a rare mode of discovery of hydatid cyst. Fistulography and CT scan are extremely useful for diagnosis. Percutaneous debridement of the hydatid cyst represents a debatable alternative to surgical therapy.
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Affiliation(s)
- S Daldoul
- Service de chirurgie générale A, hôpital Charles-Nicolle, boulevard 9 Avril 1938, 1006 Tunis, Tunisie; Faculté de médecine de Tunis, université Tunis El Manar, 15, rue Djebel Lakhdhar, 1007 La Rabta, Tunis, Tunisie.
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15
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Strong S, Steele SR, Boutrous M, Bordineau L, Chun J, Stewart DB, Vogel J, Rafferty JF. Clinical Practice Guideline for the Surgical Management of Crohn's Disease. Dis Colon Rectum 2015; 58:1021-36. [PMID: 26445174 DOI: 10.1097/dcr.0000000000000450] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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16
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Abstract
INTRODUCTION The clinical presentations of Crohn disease of the small bowel vary from low to high complexity. Understanding the complexity of Crohn disease of the small bowel is important for the surgeon and the gastroenterologist caring for the patient and may be relevant for clinical research as a way to compare outcomes. Here, we present a categorization of complex small bowel Crohn disease and review its surgical treatment as a potential initial step toward the establishment of a definition of complex disease. RESULTS The complexity of small bowel Crohn disease can be sorted into several categories: technical challenges, namely, fistulae, abscesses, bowel or ureteral obstruction, hemorrhage, cancer and thickened mesentery; extensive disease; the presence of short gut; a history of prolonged use of medications, particularly steroids, immunomodulators, and biological agents; and a high risk of recurrence. CONCLUSIONS Although the principles of modern surgical treatment of Crohn disease have evolved to bowel conservation such as strictureplasty techniques and limited resection margins, such practices by themselves are often not sufficient for the management of complex small bowel Crohn disease. This manuscript reviews each category of complex small bowel Crohn disease, with special emphasis on appropriate surgical strategy.
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17
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Gecse K, Khanna R, Stoker J, Jenkins JT, Gabe S, Hahnloser D, D'Haens G. Fistulizing Crohn's disease: Diagnosis and management. United European Gastroenterol J 2014; 1:206-13. [PMID: 24917961 DOI: 10.1177/2050640613487194] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Accepted: 03/25/2013] [Indexed: 12/13/2022] Open
Abstract
Fistulizing Crohn's disease represents an evolving, yet unresolved, issue for multidisciplinary management. Perianal fistulas are the most frequent findings in fistulizing Crohn's disease. While enterocutaneous fistulas are rare, they are associated with considerable morbidity and mortality. Detailed evaluation of the fistula tract by advanced imaging techniques is required to determine the most suitable management options. The fundamentals of perianal fistula management are to evaluate the complexity of the fistula tract, and exclude proctitis and associated abscess. The main goals of the treatment are abscess drainage, which is mandatory, before initiating immunosuppressive medical therapy, resolution of fistula discharge, preservation of continence and, in the long term, avoidance of proctectomy with permanent stoma. The management of enterocutaneous fistulas comprises of sepsis control, skin care, nutritional optimization and, if needed, delayed surgery.
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Affiliation(s)
- Krisztina Gecse
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands ; Robarts Clinical Trials, Amsterdam, the Netherlands
| | | | - Jaap Stoker
- Department of Radiology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - John T Jenkins
- Department of Surgery, St. Mark's Hospital, Harrow, London, UK
| | - Simon Gabe
- The Lennard-Jones Intestinal Failure Unit, St. Mark's Hospital, Harrow, London, UK
| | - Dieter Hahnloser
- Department of Visceral Surgery, University Hospital of Lausanne, Lausanne, Switzerland
| | - Geert D'Haens
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands ; Robarts Clinical Trials, Amsterdam, the Netherlands
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18
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Abstract
Although medical management can control symptoms in a recurring incurable disease, such as Crohn's disease, surgical management is reserved for disease complications or those problems refractory to medical management. In this article, we cover general principles for the surgical management of Crohn's disease, ranging from skin tags, abscesses, fistulae, and stenoses to small bowel and extraintestinal disease.
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Affiliation(s)
- Kim C Lu
- Division of Gastrointestinal and General Surgery, Department of Surgery, Oregon Health & Science University, Portland, OR 97239, USA.
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19
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Early experience with single-site laparoscopic surgery for complicated ileocolic Crohn’s disease at a tertiary-referral center. Surg Endosc 2011; 26:777-82. [DOI: 10.1007/s00464-011-1951-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2011] [Accepted: 09/10/2011] [Indexed: 01/30/2023]
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20
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Ashkenazi I, Olsha O, Kessel B, Krausz MM, Alfici R. Uncommon acquired fistulae involving the digestive system: summary of data. Eur J Trauma Emerg Surg 2011; 37:259-67. [PMID: 26815108 DOI: 10.1007/s00068-011-0112-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2011] [Accepted: 04/16/2011] [Indexed: 10/18/2022]
Abstract
PURPOSE Most gastrointestinal fistulae commonly occur following surgery. A minority is caused by a myriad of other etiologies and is termed by some as "uncommon fistulae". The aim of this study was to review these fistulae and their treatment. METHODS A literature review was carried out. Searches were conducted in Pubmed and related references reviewed. RESULTS Except for Crohn's disease and diverticulitis, "uncommon fistulae" are described in case reports or very small case series. Most of the patients were treated by surgery. CONCLUSIONS The anatomic features of the fistula and the etiology usually dictate the approach. Most patients will eventually need surgery to resolve this pathology.
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Affiliation(s)
- I Ashkenazi
- Surgery B Department, Hillel Yaffe Medical Center, P.O. Box 169, Hadera, 38100, Israel.
| | - O Olsha
- Surgery Department, Shaare Zedek Medical Center, Jerusalem, Israel
| | - B Kessel
- Trauma Unit, Hillel Yaffe Medical Center, Hadera, Israel
| | - M M Krausz
- Surgery B Department, Hillel Yaffe Medical Center, P.O. Box 169, Hadera, 38100, Israel
| | - R Alfici
- Surgery B Department, Hillel Yaffe Medical Center, P.O. Box 169, Hadera, 38100, Israel
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21
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Baars JE, Kuipers EJ, Dijkstra G, Hommes DW, de Jong DJ, Stokkers PCF, Oldenburg B, Pierik M, Wahab PJ, van Bodegraven AA, van der Woude CJ. Malignant transformation of perianal and enterocutaneous fistulas is rare: results of 17 years of follow-up from The Netherlands. Scand J Gastroenterol 2011; 46:319-25. [PMID: 21299339 DOI: 10.3109/00365521.2010.536251] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Malignant transformation of fistulas has been observed, particularly in perianal fistulas in Crohn's disease (CD) patients. The prevalence of adenocarcinoma in enterocutaneous fistulas and non-CD-related fistulas, however, is unknown. We investigated adenocarcinoma originating from perianal and enterocutaneous fistulas in both CD patients and non-CD patients from nine large, mostly tertiary referral, hospitals in The Netherlands. METHODS Patients suffering from fistulizing disease and either dysplasia or adenocarcinoma between January 1990 and January 2007 were identified using the nationwide automated pathology database (PALGA). Clinical and histopathological data were collected and verified using hospital patient-charts and reported by descriptive statistics. The total CD-population comprised 6058 patients. RESULTS In a study-period of 17 years, 2324 patients with any fistula were reported in PALGA. In 542 patients, dysplasia or adenocarcinoma was also mentioned. After initial review and additional detailed chart review, 538 patients were excluded, mainly because the adenocarcinoma was not related to the fistula. In the remaining four patients, all suffering from CD, adenocarcinoma originating from the fistula-tract was confirmed. The malignancies developed 25 years (IQR 10-38) after CD diagnosis, and 10 years (IQR 6-22) after fistula diagnosis. Median age at time of adenocarcinoma diagnosis was 48.3 years (IQR 43-58). Only one patient had clinical symptoms indicative for adenocarcinoma. In three other patients, the adenocarcinoma was found coincidently. CONCLUSIONS Adenocarcinoma complicating perianal or enterocutaneous fistula-tracts is a rare finding. Only 4 out of 6058 CD patients developed a fistula-associated adenocarcinoma. We could not identify any malignant transformations in non-CD-related fistulas in our 17 years study-period.
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Affiliation(s)
- Judith E Baars
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Gravendijkwal 230, Rotterdam, The Netherlands.
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22
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Yoon YS, Yu CS, Yang SK, Yoon SN, Lim SB, Kim JC. Intra-abdominal fistulas in surgically treated Crohn's disease patients. World J Surg 2010; 34:1924-9. [PMID: 20372893 DOI: 10.1007/s00268-010-0568-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Yong Sik Yoon
- Department of Colon and Rectal Surgery, University of Ulsan College of Medicine and Asan Medical Center, 388-1 Pungnap-dong, Songpa-gu, Seoul, 138-736, Korea
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23
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Taner T, Cima RR, Larson DW, Dozois EJ, Pemberton JH, Wolff BG. Surgical treatment of complex enterocutaneous fistulas in IBD patients using human acellular dermal matrix. Inflamm Bowel Dis 2009; 15:1208-12. [PMID: 19170192 DOI: 10.1002/ibd.20882] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Inflammatory bowel disease (IBD) patients represent a high-risk group for enterocutaneous fistula (ECF) formation, related to both their disease process and the need for multiple surgeries. Often the abdominal wall is significantly involved with the ECF and requires partial resection. The use of synthetic prosthetic material to reconstruct the abdominal wall after ECF surgery is associated with increased risk of infection and recurrent fistulas. Herein we report the use human acellular dermal matrix (hADM) in the surgical treatment and reconstruction of the abdominal wall in 11 consecutive IBD patients with complex and medically refractory ECF. METHODS After resection of the involved bowel segment and the overlying abdominal wall, a single sheet of hADM was used to reconstruct the defect. Pre- and perioperative risk factors were reviewed and patients were followed prospectively for a year (360 +/- 118 days). RESULTS Operative mortality was nil. Three patients (27%) developed subcutaneous seroma and there were 2 cases (18%) of superficial wound infection, all of which resolved with conservative management. The mean length of hospital stay was 13.5 (+/-7.2) days and all patients were tolerating an oral diet at the time of dismissal. There were no recurrences. One patient with Crohn's disease developed a new ECF from a separate bowel site on postoperative day 145, which was treated with the same surgical approach. No further complications have occurred. CONCLUSIONS Our results indicate that in a high-risk IBD patient population with multiple perioperative risk factors the use of hADM during ECF takedown is an effective and well-tolerated treatment option.
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Affiliation(s)
- Timucin Taner
- Division of Gastrointestinal and General Surgery, Mayo Clinic, Rochester, Minnesota 55905, USA
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24
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Severe Course of Crohn's Disease Complicated with Multiple Peristomal Fistulas. POLISH JOURNAL OF SURGERY 2009. [DOI: 10.2478/v10035-009-0030-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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25
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Abstract
The timing of the decision for operation in Crohn’s disease is based on an evaluation of the several factors such as the failure of medical treatment, complications due to the Crohn’s disease or to the farmacological therapy, development of dysplasia or cancer and growth retardation. A complete evaluation of these factors should result in operation timed to the patient’s best advantage, achieving maximal relief of symptoms with improvement of quality of life. Given the complexity and heterogeneity of the disease and the different options for treatment, is difficult to systematize when the optimal moment for the surgery is arrived. A very important factor in the management of Crohn’s disease is the multidisciplinary approach and the patient preference should be a significant factor in determining the choice of therapy. The surgery should be considered such another option in the sequential treatment of Crohn’s disease. We have analyzed the factors that are involved in the decision taking of the surgical treatment regarding to the experience and the published literature. When did the medical therapy fail? when is the appropriate moment to operate on the patient? Or which complications of Crohn’s disease need a surgery? These are some of the questions we will try to answer.
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26
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Abstract
Despite the new and ever expanding array of medications for the treatment of inflammatory bowel disease (IBD), there are still clear indications for operative management of IBD and its complications. We present an overview of indications, procedures, considerations, and controversies in the surgical therapy of IBD.
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27
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Abstract
Surgery is required in the vast majority of patients with Crohn’s disease (CD) and in approximately one-third of patients with ulcerative colitis (UC). Similar to medical treatments for IBD, significant advances have occurred in surgery. Advances in CD include an emphasis upon conservatism as exemplified by more limited resections, strictureplasties, and laparoscopic resections. The use of probiotics in selected patients has improved the outcome in patients with pouchitis following restorative proctocolectomy for UC. It is anticipated that ongoing discoveries in the molecular basis of IBD will in turn identify those patients who will best respond to surgery.
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Strong SA, Koltun WA, Hyman NH, Buie WD. Practice parameters for the surgical management of Crohn's disease. Dis Colon Rectum 2007; 50:1735-46. [PMID: 17690937 DOI: 10.1007/s10350-007-9012-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Scott A Strong
- Fletcher Allen Health Care, 111 Colchester Avenue, Fletcher 301, Burlington, Vermont 05401, USA
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Sakuraba M, Asano T, Yano T, Yamamoto S, Moriya Y. Reconstruction of an enterocutaneous fistula using a superior gluteal artery perforator flap. J Plast Reconstr Aesthet Surg 2007; 62:108-11. [PMID: 17959426 DOI: 10.1016/j.bjps.2007.09.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2006] [Revised: 01/17/2007] [Accepted: 09/11/2007] [Indexed: 12/19/2022]
Abstract
Enterocutaneous fistula is an uncommon complication of surgery for colorectal cancer. However, once a fistula has developed, treatment is complicated by previous treatments. Here, we describe an enterocutaneous fistula that developed after multiple treatments for rectal cancer in a 62-year-old woman. The woman had previously undergone several colorectal surgeries, radiation therapy and five courses of chemotherapy. Four years after the final surgery, an enterocutaneous fistula developed between the small intestine and the sacral skin. The fistula was resected, and the resulting defect was successfully reconstructed with a superior gluteal artery perforator flap.
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Affiliation(s)
- M Sakuraba
- Division of Plastic and Reconstructive Surgery, National Cancer Center Hospital East, Chiba, Japan.
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Steele SR. Operative management of Crohn's disease of the colon including anorectal disease. Surg Clin North Am 2007; 87:611-31. [PMID: 17560415 DOI: 10.1016/j.suc.2007.03.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Evaluation and management of the patient who has Crohn's disease of the colon, rectum, and anus is challenging for even the most experienced provider. Because of its broad spectrum of presentation, recurrent nature, and potential for high morbidity, the surgeon needs to not only treat the acute situation but also keep in mind the potential long-term ramifications. Although there are exciting new medications and treatment modalities yielding promising results, surgery continues to remain at the forefront for the care of these patients. This article reviews various surgical options for the patient who has Crohn's disease of the colon, rectum, and perianal region with emphasis on symptomatic resolution and optimization of function.
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Affiliation(s)
- Scott R Steele
- Colon & Rectal Surgery, Department of Surgery, Madigan Army Medical Center, Fort Lewis, WA 98431, USA.
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Dionigi G, Dionigi R, Rovera F, Boni L, Padalino P, Minoja G, Cuffari S, Carrafiello G. Treatment of high output entero-cutaneous fistulae associated with large abdominal wall defects: single center experience. Int J Surg 2007; 6:51-6. [PMID: 17869198 DOI: 10.1016/j.ijsu.2007.07.006] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2007] [Revised: 07/19/2007] [Accepted: 07/26/2007] [Indexed: 11/21/2022]
Abstract
BACKGROUND AND AIM Enteric fistulas are defined by their sites of origin, communication and flow. We evaluate the treatment of complex patients with entero-cutaneous fistulae with large abdominal wall defects. MATERIALS AND METHODS Retrospective case note review of 19 patients (15 males, median age 46 years) treated at the Department of Surgical Sciences, University of Insubria, Varese, Italy. These were distinguished by multiple/wide gastrointestinal fistula orifices, with total discontinuity of bowel. Fistulas were not covered by abdominal wall thus presenting with a giant abdominal wall defects. Surgery was planned once adequate nutritional status was present. RESULTS All fistulas resulted from previous surgery for IBD in 7 cases (37%), abdominal trauma 4 (21%), acute necrotic infected pancreatitis 3 (16%), intra-abdominal malignancy 3 (16%), and diverticular disease 2 (10%). The most common site of presentation was ileum (80%). Median fistula output was 800ml/day (range 400-1600ml/day). Seltzer's prognostic index identified malnutrition in 70% of patients at the time of presentation. The elapsed mean time from onset of fistula and elective time of surgical management were 184 days (range 20-2190 days). The VAC system was used in the last 7 patients preoperatively and in 6 patients with postoperative abdominal wound dehiscences that could not be closed immediately and who were at high risk for healing complications. There were no complications from the VAC therapy. Surgery was successful in 69% of cases. Mortality rate was 21%. Factors related to mortality were persistent malignancy, malnutrition and sepsis. CONCLUSIONS After optimization of nutritional status surgery with en bloc resection of fistula offers best results. In this series, cancer and sepsis were unfavourable factors for outcome. These fistulas may be successfully managed with a multidisciplinary approach.
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Affiliation(s)
- G Dionigi
- Department of Surgical Sciences, University of Insubria, Viale Borri 57, 21100 Varese, Italy.
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Galie KL, Whitlow CB. Postoperative enterocutaneous fistula: when to reoperate and how to succeed. Clin Colon Rectal Surg 2006; 19:237-46. [PMID: 20011327 PMCID: PMC2780112 DOI: 10.1055/s-2006-956446] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
An enterocutaneous fistula (ECF) is a potentially catastrophic postoperative complication. Although the morbidity and mortality associated with ECF have decreased over the past 50 years with modern medical and surgical care, the overall mortality is still surprisingly high, up to 39% in recent literature. It seems prudent, then, for every surgeon to have a thorough grasp of optimal treatment strategies for ECF to minimize their patients' mortality. Ultimately, the algorithm must begin with prevention. Once an ECF is diagnosed, the first step is to resuscitate and treat sepsis. The second is to control fistula output. The third step is to optimize the patient medically and nutritionally. The last step is definitive restoration of gastrointestinal continuity when necessary. Special mention is given in this article to exceptionally refractory fistulas such as those arising in the presence of inflammatory bowel disease and irradiated bowel. This plan gives a framework for the difficult task of successfully treating the postoperative ECF with a multidisciplinary approach.
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Affiliation(s)
- Kathryn L Galie
- West County Surgical Specialists, Inc., St. Louis, MO 63141, USA.
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