The staged management of complex entero‐urinary fistulae

Abstract

Objective To present the results of the staged management of complex entero-urinary ®stulae. Patients and methods Ten patients with complex enterourinary ®stulae were reviewed; all patients were referred to a national intestinal failure unit after failed treatment in other centres. Each patient was treated in three stages. The acute stage involved proximal defunctioning and distal drainage of both the gastrointestinal and urinary tracts to isolate the ®stula, together with the eradication of sepsis. The recovery stage involved total parenteral nutrition, organ support, radiological planning of surgical reconstruction and intensive nursing. The reconstructive stage followed when the patient was stable, nutritionally replenished and intra-abdominal sepsis was controlled. Surgery was undertaken jointly by urological and gastrointestinal surgeons. Results The ®stulae were treated successfully in all patients, with functional restoration in four, and/or diversion of the gastrointestinal and urological tracts in six. The mean (range) time to reconstruction was 5 (1±20) months. There were no postoperative deaths. Conclusion A staged multidisciplinary approach with delayed reconstruction can achieve a successful outcome in the management of complex enterourinary ®stulae.

Dünndarmneoblasenfistel nach radikaler Zystektomie und orthotoper Ileumersatzblase

“…Manifestiert sich die enterovesikale durch eine klassische Fäkalurie oder Pneumaturie, erfolgt die weitergehende Diagnostik und Therapie leitliniengerecht: retrograde Zystographie der Neoblase, CT des Abdomens zur anatomischen Lokalisationsdiagnostik der Fistel evident meist durch intensive Adhäsio-nen zwischen Dünndarmschlingen und der Neoblase, Revisionslaparotomie mit Fistelexzision und/oder Dünndarmseg-mentresektion [10,11].…”

“…Die Therapie der intestinalen Fistel richtet sich nach der Klinik des Patienten, der anatomischen Lokalisation und der Größe der Fistel [5,6,7,8,9,10,11]. Bei kleinen, früh nach der radikalen Zystektomie auftretenden Fisteln ohne systemische Begleitreaktionen (Fieber, Schüt-telfrost etc.)…”

“…Bladder cancer · Radical cystectomy · Orthotopic ileal neobladder · Intestinal fistula · Enteric fistula Therapie und Diät mit mittelkettigen Fettsäuren unternommen werden [7,10].…”

“…Fisteln mit systemischer Begleitreaktion und solche, die mittelfristig nach Anlage der Neoblase auftreten, sollten operativ saniert werden, nachdem die Wahrscheinlichkeit eines spontanen Fistelverschlusses bei <10% liegt, die Gefahr einer Septikämie jedoch mit 50-75% anzusetzen ist [10,11]. Hierbei ist meist ein komplexes chirurgisches Vorgehen notwendig, das in einem ersten Schritt die komplette Adhäsiolyse des Dünndarms notwendig macht.…”

Management of Enterocutaneous Fistulas

“…Surgical Drainage Surgical management of sepsis associated with the development of an enterocutaneous fistula is likely to be required when there is discontinuity between bowel ends (for example, after anastomotic dehiscence), when radiological investigations have shown multiple infected collections, or when complex fistulas are associated with internal components, including fistulation into adjacent bowel loops and the urinary bladder. 18 Studies of the outcome of surgery in the management of abdominal sepsis have clearly shown that control of the source of infection is the best prognostic determinant. 17,19 Although there are various surgical strategies for the management of abdominal sepsis associated with intestinal fistulation, the aim of surgical treatment in the management of sepsis associated with enterocutaneous fistula is principally to extirpate the focus of sepsis by exteriorizing the fistulating segment whenever possible.…”