Total Transperineal Laparoscopic Proctectomy for the Treatment of Crohn's Proctitis

INTRODUCTION

Completion proctectomy is traditionally performed using a combination of abdominal and perineal approaches. Access to and exposure of the pelvis through the abdominal cavity can be limited in patients with prior surgery or inflammatory conditions. We describe a novel technique for a total transperineal approach for proctectomy for Crohn's proctitis, avoiding technical challenges, risks, and recovery associated with abdominal surgery.

TECHNIQUE

We utilized the skills and expertise acquired from our experience with transanal total mesorectal excision to perform a total transperineal laparoscopic proctectomy in a male patient with medically refractory proctitis. He previously underwent an anterior resection, drainage of a chronic presacral abscess, omental pedicle flap transposition to the pelvis, and end colostomy for severe Crohn's colitis. The total transperineal laparoscopic proctectomy approach avoids the need for abdominal access, including the risks associated with abdominal entry, adhesiolysis, pelvic access and visualization, and wound-related issues. Following an initial intersphincteric perineal dissection, the GelPOINT Path minimal access platform is utilized to perform a total transperineal proctectomy.

RESULTS

The patient recovered uneventfully and was discharged to home 2 days after surgery. At 1-month postoperative follow-up, the patient is recovering well with complete healing of the perineal wound.

CONCLUSION

We demonstrate the feasibility, safety, and technical steps of a minimally invasive completion proctectomy for fistulizing Crohn's proctitis by using a total transperineal approach. This approach allowed us to utilize direct, inline, high-definition visualization to access and safely operate in the distal aspects of a narrow, scarred, and fibrotic pelvis while avoiding the need for any abdominal access. Advanced experience with redo pelvic and minimally invasive transanal surgery is critical. See Video at http://links.lww.com/DCR/B664.

The Value of C Reactive Protein and the Leukocytes in the Peritoneal Fluid in the Predicting Postoperative Digestive Fistulas

Anastomotic fistulas in digestive surgery are a severe complication of the patient. The identification of paraclinical laboratory investigations which would allow an early diagnosis of fistulas would lead to the optimization of patient's management. We have performed a retrospective study on 100 cancer patients, with digestive tract surgeries, between May 2016 and December 2017, in the First Clinic of General surgery and Surgical Oncology from the Bucharest Oncology Institute. The postoperative follow-up included: the testing of the C reactive protein (CRP ), and also the monitoring of the number of leukocytes (Ld) from the abdominal cavity, with probes taken from the drainage tube, all in association with the number of leukocytes in the blood (Ls) in all patients (with or without digestive fistula). By calculating the values of these tests and comparing them always with the clinical evolution of the patients, and sometimes with other tests as well, one would confirm an early diagnosis of fistula. The data obtained have shown that in patients with digestive fistulae there is a rapid growth and maintaining of increased values of serum PCR and of the leukocytes from the peritoneal cavity, values to which we associated also an increase in blood leukocytes. The modifications appear with approx. two days before the appearance of clinical signs or their confirmation through imagery (ultrasound, computed tomography). The regular and standardized follow-up in days 1, 3 and 5 postoperatively of the PCR value in blood, of the number of leukocytes in the abdominal cavity and of the serum leucocytosis, increasing the value of these parameters, could allow the early identification of the patients with a risk of fistula and the rapid selection of those which need supplementary investigations and/or surgical intervention.

[A woman with fever and a painful hip]

An immunocompromised 78-year-old woman had a painful hip and subacute fever. An abdominal CT scan revealed a diverticular sigmoid stenosis fistulating to the presacral space, with free gas in the paravertebral musculature and spinal canal. Because a deep necrotising infection was suspected, she underwent surgery and was treated with antibiotics. She recovered completely.

THE OVER-THE-SCOPE-CLIP FOR THE TREATMENT OF THE DIGESTIVE TUBE LEAKS AND TEARS: A CASE-SERIES

Digestive tube damages represent a therapeutic challenge for the gastrointestinal endoscopists. Recenty, a novel device – the-over-the-scope clip (OTSC) – has been introduced for non-surgical treatment of gastrointestinal perforations, fi stula, anastomotic leaks and refractory gastrointestinal bleeds. This study aimed to evaluate the therapeutic effi cacy of OTSC in our case series. A total of nine patients were included (six males, medain age 72 years, range 58-86). The indications were upper gastrointestinal bleeding (refractory to standard endoscopic treatment: fi ve patients, a vessel with a large caliber: one patient), fi stula in two patients, and iatrogenic perforation of the sigmoid colon in one patient. Atraumatic and traumatic versions of OTSCs with twin graspers were used. All of the patients were treated with only one OTSC, and none of the patients required additional endoscopic treatment. The OTSC procedure had 100% technical success. In a subgroup of patients with perforation and fi stulae, the clinical success was 67%, whereas in those with the bleedings it was 50%. The median follow-up was 34 days (range: 3-452). OTSC is a safe and effective device for closure of perforations and leaks. However therapeutic effi cacy was subopimal in patients with the upper gastrointestinal bleedings possibly due to the application of the sharp-teeth OTSC.

Novel treatment options for perforations of the upper gastrointestinal tract: Endoscopic vacuum therapy and over-the-scope clips

Endoscopic management of leakages and perforations of the upper gastrointestinal tract has gained great importance as it avoids the morbidity and mortality of surgical intervention. In the past years, covered self-expanding metal stents were the mainstay of endoscopic therapy. However, two new techniques are now available that enlarge the possibilities of defect closure: endoscopic vacuum therapy (EVT), and over-the-scope clip (OTSC). EVT is performed by mounting a polyurethane sponge on a gastric tube and placing it into the leakage. Continuous suction is applied via the tube resulting in effective drainage of the cavity and the induction of wound healing, comparable to the application of vacuum therapy in cutaneous wounds. The system is changed every 3-5 d. The overall success rate of EVT in the literature ranges from 84% to 100%, with a mean of 90%; only few complications have been reported. OTSCs are loaded on a transparent cap which is mounted on the tip of a standard endoscope. By bringing the edges of the perforation into the cap, by suction or by dedicated devices, such as anchor or twin grasper, the OTSC can be placed to close the perforation. For acute endoscopy associated perforations, the mean success rate is 90% (range: 70%-100%). For other types of perforations (postoperative, other chronic leaks and fistulas) success rates are somewhat lower (68%, and 59%, respectively). Only few complications have been reported. Although first reports are promising, further studies are needed to define the exact role of EVT and OTSC in treatment algorithms of upper gastrointestinal perforations.

[Clinical characteristics, diagnosis and treatment of digestive tract leakage after orthotopic liver transplantation]

OBJECTIVE

To investigate the clinical characteristics, diagnosis and treatment of digestive tract leakage after orthotopic liver transplantation (OLT).

METHODS

Sixty-one recipients had digestive tract leakage in early stage after OLT among 1173 cases from January 2000 to December 2010. There were 55 male and 6 female patients, aging from 36 to 61 years, with a median of 45 years. Digestive tract leakage included bile leakage (46 cases), gastric leakage (5 cases), duodenal leakage (1 case), jejunal leakage (4 cases), ileal leakage (1 case) and colon transversum leakage (4 cases). Ten of recipients with gastrointestinal leakage had 1 to 3 times of abdominal surgery before OLT. Abdominal drainage was used in 28 cases with bile leakage, and additionally, endoscopic retrograde cholangiopancreatography, endoscopic nasobiliary drainage and stenting were performed for 8 of them, and surgical neoplasty for another 18 patients with bile leakage. Simple surgical neoplasty of perforation was performed for 13 patients with gastrointestinal leakage, and diverticulectomy and neoplasty for 1 case with duodenal leakage, and partial jejunostomy for one severe jejunal leakage. Nutritional support was administered for all of cases.

RESULTS

The incidence rate of digestive tract leakage in early stage after OLT was 5.20% (61/1173). Intra-operative iatrogenic injury of gastrointestinal tract was occurred in 6 cases with gastrointestinal leakage. After treatment, 11 cases died of multiple organ failure resulted from severe infection, with mortality of 18.0% (11/61), including 4 cases with bile leakage, with the mortality of 8.6% (4/46), and 7 cases with gastrointestinal tract leakage, with the mortality of 46.6% (7/15). The remanent 50 cases through comprehensive treatment with a span of 1 to 3 months recovered and discharged healthily. No digestive tract leakage reoccurred in the follow-up of 6 to 84 months.

CONCLUSIONS

The morbidity of digestive tract leakage in early stage after OLT is low, but its mortality is high, especially for gastrointestinal tract leakage. High dose corticosteroids therapy, history of abdominal operation and intra-operative iatrogenic injury may be high risk factor. Comprehensive treatment is crucial for improving prognosis.

Appendico-cutaneous fistula presenting as a large wound: a rare phenomenon-brief review

Appendicular inflammation can present as a discharging fistula on the abdominal wall. We are reporting a rare case of appendico - cutaneous fistula presenting as a large wound over the right iliac region. A 60 year old female reported to the emergency with a large wound and slough on right side of the abdomen. The thin shinning serous discharge from the wound revealed actinomycosis on microbiology. Patient was successfully treated conservatively with the help of percutaneous drainage and antibiotics. On follow-up of 3 months, patient is doing well and is asymptomatic. Acute appendicitis is considered one of the elementals of general surgical disease processes, yet its presentation often confounds its diagnosis by most surgeons. Its presentation as abscess in the abdominal wall and groin is a rare clinical entity. Because of insidious onset and subtle clinical signs of resulting abscess, the diagnosis of such cases is often delayed. USG and Contrast enhanced computed tomography are important part of investigations to make diagnose and helps in the treatment.

Epidemiology and diagnosis of endograft infection

Endograft infection is reported to occur in between 0.2 and 0.7 of patients and in general presents either within four months of endograft implantation of after more than 12 months. Review of all cases reported to date reveals three modes of presentation: approximately one third of patients present with evidence of an aorto-enteric fistula (although less than half of these present with gastrointestinal haemorrhage), one third present with non specific signs of low grade sepsis (malaise, weight loss) and the remainder with evidence of severe systemic sepsis. Infection is most commonly attributed to Staphylococcus aureus. Diagnosis relies on a high index of suspicion, imaging of the aorta and periaortic tissues (computed tomography or magnetic resonance imaging) and bacteriological culture. This paper presents a detailed analysis of the features of all cases reported to date and examines the aetiology, pathogenesis and imaging of endograft infection and aorto-enteric fistula.

Diagnosis of Aortoenteric Fistulas with CT Angiography

PURPOSE

To describe the diagnostic findings of primary and secondary aortoenteric fistulas (AEFs) at computed tomographic (CT) angiography in a cohort of patients known to have AEF and to correlate those findings with those from endoscopic gastroduodenoscopy (EGD) and surgery.

MATERIALS AND METHODS

CT angiography was performed in nine patients with AEF. There were four men and five women aged 43-85 years (mean age, 67 years). All CT angiograms were retrospectively reviewed for signs of AEF. Reports from EGD, surgery, and pathologic examination were also reviewed.

RESULTS

One patient had a primary AEF, and eight patients had a secondary AEF. Findings at CT angiography were suggestive of the diagnosis in all nine patients. The two definitive CT angiographic findings were identification of the graft within the bowel lumen in two patients (22%) and active extravasation in one patient (11%), allowing the definitive diagnosis in three of the nine patients (33%). Secondary signs, which helped predict the high likelihood of the diagnosis but could also be seen in graft infection or inflammation without AEF, were as follows (in descending order of frequency): effacement of the periaortic or perigraft fat plane and the fat plane between the aorta and bowel (nine patients, 100%), perigraft soft tissue (nine patients, 100%), bowel wall thickening adjacent to the graft (eight patients, 89%), perigraft fluid (seven patients, 78%), perigraft hematoma (six patients, 67%), pseudoaneurysm or aneurysm bulge (six patients, 67%), ectopic gas (five patients, 56%), and dystrophic vascular graft calcification (one patient, 11%). The diagnosis was confirmed surgically in seven patients and with clinical follow-up in two.

CONCLUSION

CT angiography is well suited for helping make or suggesting the diagnosis of AEF and is potentially more accurate than EGD.

Abdominal Wall Sinus: An Unusual Presentation of Spilled Gallstone

Gallbladder perforation and spillage of bile is common during laparoscopic cholecystectomy. We report a case of an abdominal wall sinus due to a spilled gallstone presenting 10 years after laparoscopic cholecystectomy.

[Endoscopic treatment of gastrointestinal fistulas with biological fibrin glue]

OBJECTIVE

We summarize our experience of endoscopic treatment of gastrointestinal fistulas with fibrin glue.

PATIENTS AND METHOD

We retrospectively reviewed the outcome of 30 patients with gastrointestinal fistulas (9 internal and 21 external) refractory to standard conservative treatment for at least 10 days. Once the fistula was endoscopically located, 4 to 8 ml of reconstituted fibrin glue (Tissucol 2.0) at 37 degrees C was injected through a Duplocath catheter on a weekly basis.

RESULTS

The mean age was 59 years (32-87) and 63% were men. A total of 21.9% of the patients had high output fistulas. We were able to find all fistular orifices what were located close to the surgical anastomosis. Healing time was 17 days (4-90); 2.8 sessions were required per patient (1-5) but only 2.3 sessions were required in responders. Complete sealing of fistulas was achieved in 75%; (80% in low-output, 25% in high-output and 55.5% in internal fistulas). The frequency of fistula recurrence was 3.3%. No complications related to the sealing procedure were found. Overall mortality was 10%, but only 6.6% was related to persistence of the fistula.

CONCLUSIONS

Endoscopic treatment of fistulas with biological glue has a high success rate in sealing without complications, helping to speed up the healing process and reduce costs, particularly in low-output enterocutaneous fistulas.

Hepatopulmonary fistula caused by alveolar echinococcosis: report of a case

Alveolar echinococcosis is a parasitosis endemic to red fox habitats in the northern hemisphere. The liver is the most commonly affected organ, followed by the lungs. We report the case of an elderly woman with hepatic alveolar echinococcosis (HAE) complicated by a hepatopulmonary fistula. We performed a one-stage operation for the hepatic and pulmonary lesions through the transdiaphragmatic route via a laparotomy. We report this case to emphasize that the first-line treatment for a hepatopulmonary fistula caused by HAE should be radical surgery, which results in relief of symptoms and a good outcome.

Duodeno-pleural fistula: a rare complication of peptic ulcer perforation

Duodenopleural fistula is a very uncommon complication of peptic ulcer perforation and usually follows empyema after a subdiaphragmatic abscess rupture. We present a rare case of duodenopleural fistula following subdiaphragmatic abscess, which resulted in thoracic empyema after gastric perforation.

[Prognosis of post-operative digestive fistulas in Chu de Yopougon: Abidjan/Cote d'Ivoire]

OBJECTIVE

Because of the difficulties to manage the post-operative digestive fistulas (FDPO) and their disappointing results, the authors led this survey. It's objective is to identify the prognosis factors in order to optimize their management and improve their prognosis.

PATIENTS AND METHOD

It is a retrospective survey during 12 years, from January 1992 to December 2004 in the general and digestive surgery adult service of CHU Yopougon. It included 86 files of patients aged of 15 years at least presenting a FDPO.

RESULTS

The middle age was of 36.8 years. The death rate was 29.06%. It rose with age. The risk of death was multiplied by 5.54 over age of 55 years (OR = 5.54 and p = 0.012). The number of death rose meaningfully with the length of the diagnostic delay (p = 0.016 for OR1 = 1.64 and OR2 = 8.94. The death rate was raised more in the exposed fistulas that in the controlled fistulas (87% against 45%). In 50% of the cases the death occurred when the debit was superior or equal to 500 cc daily. Among the patients submitted to the medical treatment 69.70% had a spontaneous closing of their fistula in a middle delay of 27.18 days for extremes varying between 13 and 47 days.

CONCLUSION

The affection is very serious considering it's death rate. A precocious diagnosis and a fast and adapted management should permit to reduce this higher mortality.

[Acquierd entero-cutaneous fistulas--diagnostic and therapeutic approach]

The acquired entero-cutaneous fistulas are a current problem in the field of abdominal surgery. Most of them are postoperative--after an intestinal resection and/or anastomosis. Crohn's disease and coplicated colonic diverticulosis rank second as causal factors. The risk factors for the development of an entero-cutaneous fistula and for the poor prognosis at the same time are the next: (1) Most of the patients suffer of severe main and co-exhisting diseases; (2) The presence of previous laparotomies, radion and chemotherapy, significant disturbances in the base-acid and water-electrolyte balance; (3) The fistula itself worsens these disturbances and may doom to fail the substitutional and nutritional therapy. The diagnostics of a fistula, including its location is comparatively easy. The surgical treatment plays an important role in the therapeutic scheme, especially in cases of high-output fistulas of the small intestin. At the same time the adequate total parenteral nutrition and correction of the base-acid and water-electrolyte disbalance is also very important. Recently there are some new diagnostic methods and alternatives of the basic surgical procedures, some of them quite contraversial.

[Pyogenic liver abscess in chronic alcoholic pancreatitis]

HISTORY AND ADMISSION FINDINGS

A 44-year-old patient was transferred for further treatment of pyogenic liver abscess and a severe attack of a chronic pancreatitis for strong upper right quadrant abdominal pain and recurring fever.

INVESTIGATIONS

Laboratory results revealed a significant inflammatory constellation. Abdominal ultrasound was performed which showed a big pyogenic abscess in the right lobe of the liver. Escherichia coli and Enterococcus faecalis could be isolated from abscess aspirates. Endoscopic retrograde cholangiography (ERC) without access of the pancreatic duct showed stenosis of the Ductus hepatocholedochus which was treated with a biliary endoprothesis.

DIAGNOSIS, TREATMENT AND COURSE

Antibiotic treatment and percutaneous drainage led to complete remission of the abscess. A few days after discharge the patient returned with identical clinical symptoms. Abdominal ultrasound showed recurrence of the abscess. Because of excessively high pancreatic amylase in aspirated abscess material the patient underwent endoscopic retrograde cholangiopancreaticography (ERCP). There, a pancreatico-hepatic fistula was seen, probably the result of necrosis caused by a severe acute attack of the chronic pancreatitis. After insertion of a naso-fistular drainage, continous rinse and appropriate antibiotic therapy both abscess and fistula completely disappeared without recurrence.

CONCLUSION

The rare case of a pancreatic fistula should be considered when a pyogenic liver abscess follows an episode of acute pancreatitis or attack of chronic pancreatitis. Determination of pancreatic amylase in aspired abscess material can be an important step towards correct diagnosis.

[Diagnosis and treatment of chronic anastomotic fistulas]

Treatment of anastomotic fistulas generally implies an individualized concept. The origin of these complications is multifactorial and comprises such factors as primary operation, oncologic situation, comorbidity, and patient age as well as fistula-specific considerations such as anatomic localization, secretion volume, etc. In the case of high-output fistulas, it is of great importance to counteract fluid and electrolyte imbalances. Furthermore, skin maceration due to aggressive secretion needs to be averted. Therapeutic options include operative and endoscopic interventions. Octreotide plays a role in high-output and pancreatic fistulas. Any underlying ailment (e.g., Crohn's disease) requires an optimal disease-specific treatment which characterizes an interdisciplinary approach to such fistulas. The following article discusses general and site-specific considerations in the diagnosis and treatment of anastomotic fistulas.

Double common bile duct with ectopic drainage into the stomach. Case report and review of the literature

A rare abnormal biliary tract consisting in a double common bile duct with an ectopic biliary tree draining into the stomach is described. This congenital anomaly, associated with lithiasis in the ectopic duct, was detected for the first time on MR-cholangiopancreatography. Only 23 cases of abnormal biliary drainage into the stomach have been reported in the literature. Embryogenesis and potential risks, such as lithiasis in the ectopic duct and the development of gastric carcinoma, are discussed.

Metallic cough and pyogenic liver abscess

The curious symptom of a metallic cough in association with a pyogenic hepatic abscess should heighten awareness of a fistula. We describe a 78-year-old female with severe diverticular disease, on long-term steroid treatment for polymyalgia rheumatica. She developed a pyogenic liver abscess, treated initially by antimicrobial therapy, and subsequently drained by ultrasound and computed tomography-guided percutaneous transhepatic pigtail catheterization. This was complicated by a fistulous communication between the abscess cavity and the bronchus, confirmed by radiology. After repeated attempts at drainage and antimicrobial therapy the abscess cavity, including the hepatobronchial fistula, resolved.

Hepatobronchial fistula due to transphrenic migration of hepatic echinococcosis: MR demonstration

We present an uncommon case of hepatic hydatidosis, complicated by transphrenic migration of the cyst, in which the use of magnetic resonance performed with ultrafast, breath-hold, heavily T2-weighted sequences (HASTE) demonstrated a bronchial fistula.

[Spontaneous biliodigestive fistulae. The clinical considerations, surgical treatment and complications]

To reevaluate the current feature of spontaneous bilioenteric fistula we reviewed 81 cases who had been treated for biliary fistula between 1948 and 1998. After a review of the literature on this subject, the multiple problems relate to pathological anatomy, pathogenesis and physiopathology are discussed. Of 81 patients, 55 were women and 26 were men with the average age of 54.5 years. The most common type of fistula was cholecysto-duodenal (55 cases--68%), followed by cholecysto-colonic (11 cases--13.6%), choledocho-duodenal (7 cases--8.6%), cholecysto-gastric (4 cases--4.9%) and duodeno-left hepatic duct fistula (4 cases). The authors have found in 41 cases the gallstone ileus complications, in 12 cases inflammatory disease of biliary three, in 8 cases hemobilia, gallstone ileus with perforation and digestive hemorrhage compliances respectively. All the patients were treated with surgery. A first procedure consists of enterolithotomy, in gallstone ileus cases, followed by biliary surgery. In 14 patient the general or local conditions argued against one-stage procedure and two-stage procedure had been considered. In 63 patients a cholecystectomy was done, 15 were treated with enterolithotomy and 8 with intestinal resection. Seven patients with gastroduodenal ulcer based fistula have required a gastroduodenal resection. The mortality was 13.6% (11 cases).

Congenital intrahepatic portosystemic shunt

The authors report a congenital intrahepatic portosystemic shunt detected by angiography in a young patient with acute onset of hyperammoniemia and hepatic encephalopathy.