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Treatment strategies in 135 consecutive patients with enterocutaneous fistulas.

ABSTRACT: BACKGROUND: Enterocutaneous fistulas (ECF) pose a major challenge to every gastrointestinal (GI) surgeon. Based on earlier studies, a standardized treatment guideline was implemented. The focus of the present study was to assess that guideline and determine prognostic factors for outcome of patients with ECF, and to define a more detailed therapeutic approach including the convalescence time before restorative surgery. METHODS: All patients with ECF treated between 1990 and 2005 were included. Management consisted of controlling Sepsis, Optimization of nutritional state, Wound care, assessment of fistula Anatomy, Timing of surgery, and Surgical strategy (the SOWATS guideline). Prognostic factors were assessed by way of multiple logistic regression analysis. RESULTS: A total of 135 patients were treated at our unit. Overall closure was achieved in 118 patients (87.4%). Restorative operations for fistula closure were performed after a median of 53 days (range: 4-270 days). Restorative operations were successful in 97/107 patients (90.7%). Thirteen patients (9.6%) died. An abdominal wall defect was the most predominant negative prognostic factor for spontaneous closure (odds ratio [OR]=0.195, confidence interval [CI] 0.052-0.726, p=0.015). A strong relation was found between preoperative albumin level and surgical closure (p<0.001) and mortality (p<0.001). CONCLUSIONS: Application of the SOWATS guideline allowed a favorable outcome after a short convalescence period. Abdominal wall defects and preoperative hypoalbuminemia are important prognostic variables.

SUBMITTER: Visschers RG

PROVIDER: S-EPMC2248608 | biostudies-other | 2008 Mar

REPOSITORIES: biostudies-other

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Postoperative enterocutaneous fistulas: Management outcomes in 23 consecutive patients.

Project description:BackgroundAbout 75%-85% of enterocutaneous fistulas are postoperative. Such fistulas are still disastrous and frustrating complication for surgeon and the patient and their management remains one of major challenge and dilemma in general surgical practice. Strict adherence to treatment guideline according to SOWATS protocol could results in better outcomes.The objectiveof this study was to assess the management outcomes of 23 patients with postoperative enterocutaneous fistulas.MethodsA total of 23 consecutive patients with postoperative enterocutaneous fistulas during the period of study were included. These fistulas were classified anatomically and physiologically. The predictive factors for spontaneous closure, management outcomes and mortality rate factors for were studied.ResultsOverall Closure of the fistulas was accomplished in 16 patients (69.6%). Spontaneous closure after successful conservative management was seen in 4 patients (17.4%). The average time between fistula development and spontaneous closure was 32 days (range12-66 days). Of 19 patients underwent corrective surgery, closure was achieved in 12 patients (52.2%), thus the surgical success rate was 63.2%. Surgical intervention was performed after an average period of 28 days (range 18-42 days) from diagnosis of the fistula. Five patients with high output (21.7%) died because of sepsis, severe malnutrition and organ failure.Conclusionadherence to standardized protocol and multidisciplinary approach of patients with enterocutaneous fistulas could results in good outcomes. A reasonable period of conservative treatment is always required to optimize patient's general conditions and for spontaneous closure of fistula. Operative correction is usually required for proximal high output and complex fistulas. The complexity of the fistulas, sepsis, high output effluent and comorbidities are the main factors affecting healing rates and fistula related mortality.

| S-EPMC8144527 | biostudies-literature

Adalimumab for the treatment of fistulas in patients with Crohn's disease.

Project description:ObjectiveTo evaluate the efficacy of adalimumab in the healing of draining fistulas in patients with active Crohn's disease (CD).DesignA phase III, multicentre, randomised, double-blind, placebo controlled study with an open-label extension was conducted in 92 sites.PatientsA subgroup of adults with moderate to severely active CD (CD activity index 220-450) for >or=4 months who had draining fistulas at baseline.InterventionsAll patients received initial open-label adalimumab induction therapy (80 mg/40 mg at weeks 0/2). At week 4, all patients were randomly assigned to receive double-blind placebo or adalimumab 40 mg every other week or weekly to week 56 (irrespective of fistula status). Patients completing week 56 of therapy were then eligible to enroll in an open-label extension.Main outcome measuresComplete fistula healing/closure (assessed at every visit) was defined as no drainage, either spontaneous or with gentle compression.ResultsOf 854 patients enrolled, 117 had draining fistulas at both screening and baseline (70 randomly assigned to adalimumab and 47 to placebo). The mean number of draining fistulas per day was significantly decreased in adalimumab-treated patients compared with placebo-treated patients during the double-blind treatment period. Of all patients with healed fistulas at week 56 (both adalimumab and placebo groups), 90% (28/31) maintained healing following 1 year of open-label adalimumab therapy (observed analysis).ConclusionsIn patients with active CD, adalimumab therapy was more effective than placebo for inducing fistula healing. Complete fistula healing was sustained for up to 2 years by most patients in an open-label extension trial.

| S-EPMC2689393 | biostudies-literature

Treatment Options in Gastrointestinal Cutaneous Fistulas.

Project description:Enterocutaneous fistulas occur most commonly following surgery. A minority of them is caused by a myriad of other etiologies including infection, malignancy, and radiation. While some fistulas may close spontaneously, most patients will eventually need surgery to resolve this pathology. Successful treatment entails adoption of various methods of treatment aimed at control of sepsis, protection of surrounding skin and soft tissue, control of fistula output, and maintenance of nutrition, with eventual spontaneous or surgical closure of the fistula. The aim of this article is to review the various treatment options in their appropriate context.

| S-EPMC5553539 | biostudies-other

Gene expression data of 135 patients presenting colorectal adenoma

Project description:Gene expression profiles of 135 patients presenting with colorectal adenomas during surgery or colonoscopy were obtained using Affymetrix U133+ arrays.

2018-12-01 | GSE117607 | GEO

Hyperbaric oxygen therapy for the treatment of perianal fistulas in 20 patients with Crohn's disease.

Project description:BackgroundPositive effects of hyperbaric oxygen on perianal fistulas in Crohn's disease have been reported.AimTo assess efficacy, safety and feasibility of hyperbaric oxygen in Crohn's disease patients with therapy-refractory perianal fistulas.MethodsTwenty consecutive patients were recruited at the out-patient fistula clinic of the Amsterdam UMC. Crohn's disease patients with high perianal fistula(s) failing conventional treatment for over 6 months were included. Exclusion criteria were presence of a stoma, rectovaginal fistula(s) and recent changes in treatment regimens. Patients received treatment with 40 hyperbaric oxygen sessions and outcome parameters were assessed at Week 16.ResultsSeven women and 13 men were included (median age 34 years). At Week 16, median scores of perianal disease activity index and modified van Assche index (co-primary outcome parameters) decreased from 7.5 (95% CI 6-9) to 4 (95% CI 3-6, P < 0.001), and from 9.2 (95% CI 7.3-11.2) to 7.3 (95% CI 6.9-9.7, P = 0.004) respectively. Perianal disease activity index scores ≤4 (representing inactive perianal disease) were observed in 13/20 patients (65%). Twelve patients showed a clinical response (60%) and four (20%) clinical remission, assessed with fistula drainage assessment. Median C-reactive protein and faecal calprotectin levels decreased from 4.2 mg/mL (95% CI 1.6-8) to 2.2 (95% CI 0.9-4.3, P = 0.003) and from 399 µg/g (95% CI 52-922) to 31 (95% CI 16-245, P = 0.001), respectively.ConclusionsWe found significant clinical, radiological and biochemical improvement in Crohn's disease patients with therapy-refractory perianal fistulas after treatment with hyperbaric oxygen.Clinical trial registrationwww.trialregister.nl/trial/6489.

| S-EPMC7898636 | biostudies-literature

Nanocomposite hyaluronic acid-based hydrogel for the treatment of esophageal fistulas.

Project description:Fistulas are abnormal connections between two body parts that can impair the quality of life. The use of biological glues represents the least invasive procedure to fill the fistula; however, it is limited by the need of multiple injections, the persistence of infection and the failure in the treatment of high-output fistulas. We describe herein the use of an injectable nanocomposite hydrogel that is able to form in situ a tissue-mimicking matrix as an innovative material for the treatment of esophageal fistulas. Injectable hydrogels that have the dual advantage of being implantable with a minimally invasive approach and of adapting their shape to the target cavity, while the introduction of mesoporous silica nanoparticles opens the possibility of drug/biomolecules delivery. The hydrogel is based on hyaluronic acid (HA), the crosslinking process occurs at physiological conditions leading to a hydrogel made of >96% by water and with a large-pore micro-architecture. The kinetic profile of the hydrogel formation is studied as a function of HA molecular weight and concentration with the aim of designing a material that is easily injectable with an endoscopic needle, is formed in a time compatible with the surgical procedure and has final mechanical properties suitable for cell proliferation. The in vivo experiments (porcine model) on esophageal-cutaneous fistulas, showed improved healing in the animals treated with the hydrogel compared with the control group.

| S-EPMC8095189 | biostudies-literature

Robotic Management of Rectourethral Fistulas After Focal Treatment for Prostate Cancer.

Project description:OBJECTIVE:To describe our management strategy for rectourethral fistula (RUF) after focal treatment for prostate cancer (PCa) using 2 cases as an example. Almost 50% of RUFs are associated with energy treatment modalities for PCa. The adjacent damage to healthy tissue along with limited pliability of it makes the success of the repair troublesome. There is no standardized approach for these scenarios. MATERIALS AND METHODS:For case 1, an 83-year-old man underwent cryotherapy for PCa. On postoperative day 14, he presented with urine per rectum. Cystoscopy confirmed the presence of an RUF. Urinary and fecal diversions were unsuccessful. Three months later, robotic surgical repair was performed. For case 2, an 85-year-old man underwent salvage therapy for PCa with high-intensity focused ultrasound after previous treatment with external beam radiation therapy. Two months postoperatively, he presented with urine per rectum. A computed tomography scan confirmed the presence of an RUF. Robotic surgical repair was subsequently performed. RESULTS:Both patients underwent robotic-assisted RUF repair, including salvage prostatectomy , rectal defect closure, and omental flap placement. In the first case, healthy urethra was present after the salvage prostatectomy, and the next step was completion of a vesicourethral anastomosis. In the second case, the next step was closure of the bladder neck and suprapubic tube placement due to the extensive tissue destruction the residual urethra. Success was confirmed with imaging studies and no reported symptoms at 9 and 4 months, respectively. CONCLUSION:The robotic system is useful for the treatment of a complicated RUF. The optimal reconstruction strategy depends on the ability to reach the distal urethra, the patients' characteristics, and preferences.

| S-EPMC9235520 | biostudies-literature

Efficacy of Permacol injection for perianal fistulas in a tertiary referral population: poor outcome in patients with complex fistulas.

Project description:AimInjection of Permacol collagen paste can be used as a sphincter-sparing treatment for perianal fistulas. In a tertiary referral population we aimed to evaluate the efficacy of Permacol injection and the clinical and fistula-related factors associated with recurrence.MethodThis was a retrospective analysis of consecutive patients with perianal fistulas treated with Permacol injection at a specialist centre between June 2015 and April 2019. Endoanal ultrasonography was systematically reanalysed, blinded to treatment outcome. Rectovaginal, anovaginal and Crohn's disease fistulas were excluded. Healed fistulas were defined as absent anal symptoms and a closed external opening on physical examination at a minimum follow-up of 6 months. Regression analyses were performed to identify factors associated with unhealed fistulas.ResultsA total of 90 patients (51 men; median age 45 years) were analysed. Seventy-two (80.0%) patients had complex perianal fistulas (greater than one-third sphincter involvement or multiple tracts). After a single Permacol injection, fistulas were healed in 20 (22.2%) patients at 3 months follow-up and in 18 (20.0%) patients at a median follow-up of 30 months (interquartile range 17-37). Eight (11.1%) patients with unhealed fistulas had significant improvement in their symptoms. Complex fistulas were significantly associated with unhealed status [OR 3.53 (95% CI 1.12-11.09); p = 0.031]. Twenty patients underwent subsequent Permacol injections, which were successful in six (30.0%) patients after one (n = 3) or two (n = 3) additional injections.ConclusionThis largest study to date in patients with mainly complex perianal fistulas, demonstrated that the efficacy of a single Permacol injection was only 20%. Complex fistulas were associated with a poor outcome.

| S-EPMC8453864 | biostudies-literature

Endoscopic management of colovaginal fistulas in advanced cancer patients.

Project description:Background and Aims:Colovaginal fistula (CVF) in cancer patients can cause significant morbidity. In addition to causing local symptoms and infections, the constant stool leakage contributes to a poor quality of life, psychological distress, and possible social isolation. Patients with CVFs often have advanced disease, poor nutrition, and complex anatomy, making them poor candidates for major surgical interventions. Advancement in endoscopic tools has made endoscopic management possible. Endoscopic management is less invasive, is associated with prompt recovery, and can significantly improve the quality of life of patients and possibly allow them to resume systemic therapy. Methods:In this video case series, 3 cases of CVF patients treated endoscopically are presented to demonstrate the use of the currently available tools and techniques. The strategy used for the closure of the 3 CVFs was dependent on the size and etiology of the fistulas. Results:Technical and clinical success was achieved in all 3 situations. There were no procedure-related adverse events. Conclusion:These cases demonstrate the use of the cap to perform vaginal endoscopy; the use of the over-the-scope clips, covered stents, and endoscopic suturing; and how they can facilitate the closure of fistulas in patients who are poor surgical candidates.

| S-EPMC6544833 | biostudies-literature

Transcriptomics modification consecutive to AS1842856 treatment in primary T lymphocytes

Project description:We have observed that the FOXO1 inhibitor AS1842856 induces a significant increase of both the bioenergetics and transcriptional activity of human T cells, together with a significant increase in their size, without any cell division. These modifications are accompanied by a decrease of p27 expression, contrasting with an increase of CDK2 cellular levels and by the phosphorylation of Rb and SAMHD1 proteins. As these changes are known to be characteristic of cells undergoing a G0 to G1 progression. To get an overall view of these changes in T-cell metabolism, we performed gene expression microarray analysis of PBT cultured during 7 days in the presence or not of AS1842856. We conclude that inhibition of FOXO1 by AS1842856 is sufficient to induce a profound reprogramming of human T lymphocytes, regulating their exit from quiescence.

2019-03-08 | GSE125328 | GEO

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