Search Results (12)

Background/Objectives: Crohn’s disease is a chronic inflammatory condition with periods of exacerbation and remission that can involve any part of the gastrointestinal tract. The basic intestinal manifestation is frequently accompanied by extraintestinal involvement and may lead to complications such as perforations, fistulas and abscesses. Despite Crohn’s disease being the most common reason of intestinal perforation, the other causes should be considered as well. Internalization of a foreign body, although rare, may still occur, especially in the pediatric population. Methods: The following case report presents the medical history of an 11-year-old patient who developed an enterocutaneous fistula two years after the diagnosis of Crohn’s disease. Data analysis was carried out on the basis of patient medical records. Results: The fistula formed in the course of biological treatment during a period free of other symptoms indicating disease exacerbation. The imaging tests revealed the presence of a foreign body in the gastrointestinal tract, which could have been a potential cause of the observed inflammation that resulted in the development of the fistula. Conclusions: The presented case report as well as the literature indicate a correlation between the formation of intestinal fistulas and an active disease process. However, in the absence of symptoms of Crohn’s disease exacerbation, other causes should be considered. Full article

Introduction: High-risk neuroblastoma, particularly in the relapse/refractory (R/R) setting, poses unique challenges to obtaining the representative-quality tissue that is mostly required for molecular analysis. This study explores the use of 123I-MIBG radioguided surgery to access complex locations of MIBG-positive neuroblastoma as a tool to overcome the difficulties associated with repeated surgeries in these patients. Methods: This study is a retrospective review of all patients with R/R neuroblastoma and MIBG-uptaking lesions who underwent radioguided surgery between February 2020 and 2023 at SJD Barcelona Children’s Hospital. The Europrobe 3.2 gamma probe was used to identify neuroblastoma tissue in the operating room. Results: Ten patients were identified. Radioguided surgery was useful in all patients. One patient with previous multiple operations developed an entero-cutaneous fistula with posterior full recovery. Mean surgical time was 111.7 min. The gamma probe identified 100% of neuroblastoma lesions which were all completely removed (123I-MIBG-SPECT/CT negative post-surgery). Pathology and molecular studies could be successfully performed in all samples. Conclusions: 123I-MIBG radioguided surgery proved effective in obtaining viable tissue from difficult-to-access sites in high-risk relapsed neuroblastoma. Full article

Enteric fistulas are a common problem in gastrointestinal tract surgery and remain associated with significant mortality rates, due to complications such as sepsis, malnutrition, and electrolyte imbalance. The increasingly widespread use of open abdomen techniques for the initial treatment of abdominal sepsis and trauma has led to the observation of so-called entero-atmospheric fistulas. Because of their clinical complexity, the proper management of enteric fistula requires a multidisciplinary team. The main goal of the treatment is the closure of enteric fistula, but also mortality reduction and improvement of patients’ quality of life are fundamental. Successful management of patients with enteric fistula requires the establishment of controlled drainage, management of sepsis, prevention of fluid and electrolyte depletion, protection of the skin, and provision of adequate nutrition. Many of these fistulas will heal spontaneously within 4 to 6 weeks of conservative management. If closure is not accomplished after this time point, surgery is indicated. Despite advances in perioperative care and nutritional support, the mortality remains in the range of 15 to 30%. In more recent years, the use of negative pressure wound therapy for the resolution of enteric fistulas improved the outcomes, so patients can be successfully treated with a non-operative approach. In this review, our intent is to highlight the most important aspects of negative pressure wound therapy in the treatment of patients with enterocutaneous or entero-atmospheric fistulas. Full article

Introduction: Ehlers–Danlos syndromes (EDS) comprise a rare variety of genetic disorders, affecting all types of collagen. Herein, we describe a case of the vascular type of EDS, with coexisting segmental absence of intestinal musculature, while simultaneously performing a narrative review of the existing literature. Case Presentation: A 23-year-old male patient with a history of multiple abdominal operations due to recurrent bowel perforations and the presence of a high-output enterocutaneous fistula was admitted to our surgical department for further evaluation and treatment. After detailed diagnostic testing, the diagnosis of vascular-type EDS (vEDS) was made and a conservative therapeutic approach was adopted. In addition, a comprehensive review of the international literature was carried out by applying the appropriate search terms. Results: The diagnosis of vEDS was molecularly confirmed by means of genetic testing. The patient was treated conservatively, with parenteral nutrition and supportive methods. Thirty-four cases of bowel perforation in vEDS have been reported so far. Interestingly, this case is the second one ever to report co-existence of vEDS with Segmental Absence of Intestinal Musculature. Conclusions: Establishing the diagnosis of vEDS promptly is of vital significance in order to ensure that patients receive appropriate treatment. Due to initial non-specific clinical presentation, EDS should always be included in the differential diagnoses of young patients with unexplained perforations of the gastrointestinal tract. Full article

Objectives: The aim of the study was to present the results obtained in our experiment regarding the management of postoperative enterocutaneous fistulas (PECF). Materials and Methods: We conducted a retrospective study on 64 PECF registered after 2030 abdominal surgeries (1525 digestive tract surgeries and 505 extra-digestive ones) over a period of 7 years (1st of January 2014–31th of December 2020) in the 1st and 2nd Surgery Clinics, Clinical County Emergency Hospital of Craiova, Romania. The group included 41 men (64.06%) and 23 women (35.34%), aged between 21–94 years. Of the cases, 71.85% occurred in elderly patients over 65 years old. Spontaneous fistulas in Crohn’s disease, intestinal diverticulosis, or specific inflammatory bowel disease were excluded. Results: The overall incidence of 3.15% varied according to the surgery type: 6.22% after gastroduodenal surgery, 1.78% after enterectomies, 4.30% after colorectal surgery, 4.28% after bilio-digestive anastomoses, and 0.39% after extra-digestive surgery. We recorded a 70.31% fistula closure rate, 78.94% after exclusive conservative treatment and 57.61% after surgery; morbidity was 79.68%, mortality was 29.68%. Conclusion: PECF management requires a multidisciplinary approach and is carried out according to an algorithm underlying well-established objectives and priorities. Conservative treatment including resuscitation, sepsis control, output control, skin protection, and nutritional support is the first line treatment; surgery is reserved for complications or permanent repair of fistulas that do not close under conservative treatment. The therapeutic strategy is adapted to topography, morphological characteristics and fistula output, age, general condition, and response to therapy. Full article

Short bowel syndrome (SBS) and enterocutaneous or enteroatmospheric fistulas are common indications for home parenteral nutrition (HPN). However, there are few data describing factors influencing surgical decision-making or outcomes particularly following fistula development. We aimed to compare outcomes between patients with SBS and fistulas and explore surgical decision-making. HPN-dependent adults from 2001–2018 at a national reference centre were included in this study. HPN cessation was analysed using death as competing risk. In total, 465 patients (SBS (62%), fistula (38%)) were included, with median HPN dependency of 2.6 years. In total, 203 patients underwent reconstructive surgery; while frailty was the commonest reason for not undergoing surgery (49.2%), 22.7% declined surgery. Overall, 170 ceased HPN, with a probability of 13.8%, 34.1% and 38.3% at 1, 5 and 10 years, respectively. Patients undergoing surgery had higher nutritional autonomy rates (109.8 incidences/1000 patient years) compared to those not undergoing surgery (18.1 incidences/1000 patient years; p < 0.001). A total of 295 patients (63.4%) were predicted to cease HPN based on gastrointestinal anatomy but only 162/295 (54.9%) achieved this; those unable to do so were older with a higher comorbidity index. There were no differences in long-term nutritional and survival outcomes or surgical decisions between patients with SBS and fistulas, or between enterocutaneous and enteroatmospheric fistulas. This study represents one of the largest datasets describing the ability of HPN-dependent patients with SBS or fistulas to achieve nutritional autonomy. While reconstructive surgery facilitates HPN cessation, approximately one-fifth of patients declined surgery despite HPN dependency. These data will better inform patient expectation and help plan alternative therapies. Full article

Purpose: Complex enteric fistulas (CEF) represent general surgeons’ nightmare. This paper aims to explore the impact on failure-to-rescue (FTR) rate of a standardised and integrated surgical and critical care step-up approach. Methods: This was a retrospective observational cohort study. Patients treated for CEF from 2009 to 2019 at Niguarda Hospital were included. Each patient was approached following a three-step approach: study phase, sepsis control and strategy definition phase, and surgical rescue phase. Results: Sixteen patients were treated for CEF. Seven fistulas were classified as complex entero-cutaneous (ECF) and nine as entero-atmospheric fistula (EAF). Median number of surgical procedures for fistula control before definitive surgical attempt was 11 (IQR 2–33.5). The median time from culprit surgery and the first access at Niguarda Hospital to definitive surgical attempt were 279 days (IQR 231–409) and 120 days (IQR 34–231), respectively. Median ICU LOS was 71 days (IQR 28–101), and effective hospital LOS was 117 days, (IQR 69.5–188.8). Three patients (18.75%) experienced spontaneous fistula closure after conversion to simple ECF, whereas 13 (81.25%) underwent definitive surgery for fistula takedown. Surgical rescue was possible in nine patients. Nine patients underwent multiple postoperative revision for surgical complications. Four patients failed to be rescued. Conclusion: An integrated step-up rescue strategy is crucial to standardise the approach to CEF and go beyond the basic surgical rescue procedure. The definition of FTR is dependent from the examined population. CEF patients are a unique cluster of emergency general surgery patients who may need a tailored definition of FTR considering the burden of postoperative events influencing their outcome. Full article

Enterocutaneous fistula (ECF) is an abnormal connection between the gastrointestinal tract and the skin; by some estimates, it represents 88.2% of all fistulae. It can either develop spontaneously due to underlying malignancy, inflammatory bowel disease, radiation exposure, or, more commonly, as a complication of gastrointestinal surgery. A 75-year-old woman was treated for a small bowel enterocutaneous fistula that developed after laparoscopic cholecystectomy using a HANAROSTENT self-expanding metal stent (SEMS) to cover the fistula. Seven months later, the patient was discharged. For the following 2 years, the patient refused the reconstructive surgery until stent obstruction occurred. After optimizing the patient’s nutritional status, laparotomy and small bowel resection were performed successfully. The use of SEMS in fistulas of the lower gastrointestinal tract is a heavily debated and fairly under-researched topic, especially in the context of enterocutaneous fistulas. No international guidelines officially recommend using SEMS in the small bowel ECF. Full article

Introduction. Stoma formation in neonates is often a life-saving procedure across a variety of conditions but is still associated with significant morbidity. Tube stoma technique was originally described for short bowel patients, but in selected cases of neonates this approach could prevent the incidence of stoma-related complications. The aim of the study was to evaluate the safety and utility of tube stomas as an alternative to conventional enterostomy in the neonatal population. Material and Methods. A retrospective multicentre analysis of neonates undergoing emergency laparotomy and tube stoma formation between 2005 and 2017 was performed. Tube stoma complications were analysed. The investigation focused on stricture, skin lesion, enteric fistula and prolapse. Results. Thirty-seven neonates underwent tube stoma fashioning during the study period. Tube-stoma complications were limited to three patients (8.1%), with two children (5.4%) requiring additional stoma surgery during the first 30 days because of an enterocutaneous fistula, and one child (2.7%) for bowel stenosis. Conclusions. In select neonates, such as those with proximal enteric stomas, the tube stoma avoids some of the commonly encountered complications (prolapse, skin excoriation). Further prospective studies are needed to validate these findings in order for us to recommend this technique as superior. Full article

The frequency of invasive fungal infections shows a rising trend as well as a high morbidity and mortality. Among the causative agents, a shift toward the non-albicans Candida species including Candida glabrata species complex is being observed in several centers. Echinocandin resistance is increasingly published; however, isolates presenting with an in vitro resistance have not yet been reported from Turkey. We, herein, report the first FKS mutant and phenotypically echinocandin-resistant C. glabrata clinical strains from a single center in Turkey. In a 43-year-old female patient, several enterocutaneous fistulae developed after a long term hospitalization period and several complicated surgeries. She eventually required parenteral nutrition via a tunneled central venous catheter (CVC). Following a number of bacteremic and fungemic episodes as well as intensive antimicrobial interventions (including fluconazole, caspofungin and anidulafungin), a CVC-related candidemia caused by C. glabrata was detected. The isolated strain yielded high minimum inhibitory concentration (MIC) values for echinocandins and was categorized as resistant. A resistance-related mutation was detected in FKS2 HS1 (D666V). Blood cultures remained negative after the removal of the CVC and treatment with caspofungin and high-dose fluconazole. Following this first case, two additional C. glabrata strains with high echinocandin MICs were isolated from the urine cultures of two unrelated patients from different wards with different mutations in FKS2 HS1 (S663P and delF659). Our findings indicate that routine antifungal susceptibility testing is crucial and underlines the need for attention for the increasing trend of acquired echinocandin resistance in C. glabrata. Full article

Background and Aims: An enterocutaneous fistula (ECF) poses a major surgical problem. The definitive surgical repair of persistent fistulas remains a surgical challenge with a high rate of re-fistulation and mortality, and the reasons for that is not the surgical technique alone. Enhanced Recovery after Surgery (ERAS^®) is an evidence-based multimodal perioperative protocol proven to reduce postoperative complications. The aim of the study was to assess the clinical value of the ERAS protocol in surgical patients with ECF. Methods: ERAS protocol was used in all patients scheduled for surgery for ECF at the Stanley Dudrick’s Memorial Hospital in Skawina between 2011 and 2020. A multidisciplinary team (MDT) was in charge of the program and performed annual audits. A consecutive series of 100 ECF patients (44 females, 56 males, mean age 54.1 years) were evaluated. Postoperative complications rate, readmission rate, length of hospital stay, prevalence of postoperative nausea and vomiting were assessed. Registered under ClinicalTrials.gov Identifier no. NCT04771832. Results: ERAS protocol was successfully introduced for ECF surgeries; however, eight modifications to the ERAS program was performed in 2015. They led to improvement of surgical outcomes: reduction of postoperative nausea and vomiting (15 vs. 17% patients, p = 0.025), overall complication rate (11 vs. 10, p = 0.021), median length of hospital stay (overall and after surgery, p = 0.022 and 0.002, respectively). Conclusions: ERAS protocol can be successfully used for ECF patients. Prescheduled audits can contribute to the improvement of care. Full article

Granulomatous appendicitis is a very rare entity in children. It is related to Crohn’s disease in only 5–10% of the cases. The diagnosis of Crohn’s disease is a real challenge in the pediatric population, especially when its initial manifestation is acute appendicitis. Herein, we present a 13-year-old boy admitted for acute appendicitis. The histopathological examination was conclusive for acute granulomatous appendicitis. The development of an entero-cutaneous fistula has complicated the postoperative evolution. The failure of the conservative management required ileocecal resection. The pathological examination revealed Crohn’s disease. The one-year follow-up on the patient din not reveal any complications. We strongly support the importance of the histopathological examination of the entirely removed appendix. Careful assessment of granulomatous appendicitis is needed in order to establish its possible etiology and to initiate the adequate treatment. Full article