Post-traumatic rectourethral fistula in an adolescent managed via a transperineal approach using a local gluteal tissue interposition flap: a case report

Background Rectourethral fistula is a rare disease with a wide variety of etiologies and clinical presentations. A definitive surgical procedure for rectourethral fistula repair has not been established. Case presentation A 13-year-old boy sustained a penetrating injury to the perineum, and developed a symptomatic rectourethral fistula thereafter. Conservative management through urinary diversion and transanal repair was unsuccessful. Fecal diversion with loop colostomy was performed, and three months later, a fistula repair was performed via a transperineal approach with interposition of a local gluteal tissue flap. There were no postoperative complications, and magnetic resonance imaging studies confirmed the successful closure of the fistula. The urinary and fecal diversions were reverted 1 and 6 months after the fistula repair, respectively, and postoperative excretory system complications did not occur. Conclusions The transperineal approach with interposition of a local gluteal tissue flap provides a viable surgical option for adolescent patients with rectourethral fistulas who are unresponsive to conservative management.

Case Report of a Novel Technique for Fecal Diversion

An estimated 100,000 individuals within the United States experience operations that result in a colostomy or ileostomy each year. Ostomy formation is used in surgery for operations involving several pathologies involving the small intestine or colon. Evidence shows that loop ileostomy or loop colostomy for fecal diversion effectively reduce the complications of anastomotic dehiscence. Anastomotic leak can cause significant morbidity and mortality. The role of temporary fecal diversion though a loop ileostomy or colostomy is vital in protecting tenuous anastomoses in the pelvis, immunocompromised patients, or those who are septic. 4 We present a case of a patient with a perforated colon cancer who required an innovative technique for fecal diversion.

Fecal diversion does not support healing of anus-near pressure ulcers in patients with spinal cord injury—results of a retrospective cohort study

Study Design Retrospective cohort study including spinal cord injured patients with anus-near pressure ulcers. Objective The primary objective was to evaluate the impact of stool diversion via stoma on the decubital wound healing. Secondary objectives included the risk of complications and ulcer recurrence. Associations between the wound healing and potentially interfering parameters were determined. Setting University hospital with a spinal cord injury unit. Methods A total of 463 consecutive patients who presented with a decubitus were retrospectively included. Patients with and without a stoma were compared using descriptive and explorative statistics including multiple regression analysis. Results The severity of the pressure ulcers was determined as stage 3 in two-thirds and stage 4 in one-third of all cases. The wound healing lasted longer in the 71 stoma-presenting patients than in the 392 patients with undeviated defecation (77 vs. 59 days, p = 0.02). The age (regression coefficient b = 0.41, p = 0.02), the ASA classification (b = 16.04, p = 0.001) and the stage of the ulcers (b = 19.65, p = 0.001) were associated with prolonged ulcer treatment in the univariate analysis. The multiple regression analysis revealed that the fecal diversion (b = −18.19, p = 0.03) and the stage of the ulcers (b = 21.62, p = 0.001) were the only predictors of delayed wound healing. Conclusion The presence of a stoma is not related to improved wound healing of ulcers near the anus. On the contrary, stoma patients needed more time until complete wound healing, conceivably related to selection bias. Nonetheless, we currently do not recommend fecal diversion to be the standard concept for decubitus treatment.

Is Intestinal Diversion an Effective Treatment for Distal Crohn’s Disease?

Background Fecal diversion with an ileostomy is selectively used in cases of medically refractory Crohn’s proctocolitis or advanced perianal disease. The aim of this study was to evaluate clinical improvement after fecal diversion in Crohn’s disease (CD) and factors associated with clinical improvement. Methods A retrospective chart review of adult CD patients undergoing ileostomy formation for distal disease between 2000 and 2019 at 2 CD referral centers was conducted. The primary outcome was the rate of clinical improvement with diversion that allowed for successful restoration of intestinal continuity. Secondary outcomes included the rate of clinical and endoscopic improvement after fecal diversion, ileostomy morbidity, need for subsequent total proctocolectomy and end ileostomy, and factors associated with a clinical response to fecal diversion. Results A total of 132 patients with a median age of 36 years (interquartile range, 25–49) were included. Mean duration of disease was 16.2 years (10.4) years. Indication for surgery was medically refractory proctocolitis with perianal disease (n = 59; 45%), perianal disease alone (n = 24; 18%), colitis (n = 37; 28%), proctitis (n = 4; 3%), proctocolitis alone (n = 4; 3%), and ileitis with perianal disease (n = 4; 3%). Medications used before surgery included corticosteroids (n = 59; 45%), immunomodulators (n = 55; 42%) and biologics (n = 82; 62%). The clinical and endoscopic response to diversion was 43.2% (n = 57) and 23.9% (n = 16). At a median follow-up of 35.3 months (interquartile range, 10.6–74.5), 25 patients (19%) had improved and had ileostomy reversal, but 86 (65%) did not improve, with 50 (38%) undergoing total proctocolectomy for persistent symptoms. There were no significant predictors of clinical improvement. Conclusions The use of a “temporary” ileostomy is largely ineffective in achieving clinical response.

The microbiological profile of patients with Fournier’s gangrene: A retrospective multi-institutional cohort study

Objectives: To evaluate the role of the microbiological profile and of disease-related factors in the management of patients affected with Fournier’s gangrene (FG). Patients and methods: Data regarding patients admitted for FG at nine Italian Hospitals (March 2007–June 2018) were collected. Patients were stratified according to the number of microorganisms documented: Group A – one microorganism; Group B – two microorganisms; Group C – more than three microorganisms. Baseline blood tests, dedicated scoring systems, predisposing risk factors, disease’s features, management and post-operative course were analyzed. UpSet technique for visualizing set intersections in a matrix layout and Cuzick’s nonparametric test for trend across ordered groups were used. Results: Eighty-one patients were available for the analysis: 18 included in Group A, 32 in Group B, 31 in Group C. The most common microorganism isolated was Escherichia coli. In Group B-C, Escherichia coli was often associated to Enterococcus faecalis, Pseudomonas aeruginosa, and Klebsiella pneumoniae. Statistically significant positive association was highlighted among the number of pathogens (Group A vs B vs C) and serum C-reactive Protein ( p < 0.001), procalcitonin ( p = 0.02) and creatinine ( p = 0.03). Scoring systems were associated with the number of microorganisms detected ( p < 0.02). A significant association between the number of microorganisms and the use of VAC therapy and need of a fecal diversion was found ( p < 0.02). The number of microorganisms was positively associated with the length of stay (LOS) ( p = 0.02). Ten weeks after initial debridement, wound closure was achieved in 11 (91.7%), 22 (84.6%) and 20 (80%) patients in Group A, B, and C, respectively, with no differences in overall survival. Conclusion: Polymicrobial infections in FG are positively associated with inflammatory scores, the need for fecal diversion and the LOS. This results may help the counseling and the clinical management of this rare niche of patients.

Fecal Diversion for Perianal Crohn Disease in the Era of Biologic Therapies: A Multicenter Study

Background The natural history of perianal Crohn disease (PCD) after fecal diversion in the era of biologics is poorly understood. We assessed clinical and surgical outcomes after fecal diversion for medically refractory PCD and determined the impact of biologics. Methods We performed a retrospective, multicenter study from 1999 to 2020. Patients who underwent fecal diversion for refractory PCD were stratified by diversion type (ostomy with or without proctectomy). Times to clinical and surgical outcomes were estimated using Kaplan-Meier methods, and the association with biologics was assessed using multivariable Cox proportional hazards models. Results Eighty-two patients, from 3 academic institutions, underwent a total of 97 fecal diversions: 68 diversions without proctectomy and 29 diversions with proctectomy. Perianal healing occurred more commonly after diversion with proctectomy than after diversion without proctectomy (83% vs 53%; P = 0.021). Among the patients who had 68 diversions without proctectomy, with a median follow-up of 4.9 years post-diversion (interquartile range, 1.66-10.19), 37% had sustained healing, 31% underwent surgery to restore bowel continuity, and 22% underwent proctectomy. Ostomy-free survival occurred in 21% of patients. Biologics were independently associated with avoidance of proctectomy (hazard ratio, 0.32; 95% confidence interval, 0.11-0.98) and surgery to restore bowel continuity (hazard ratio, 3.10; 95% confidence interval, 1.02-9.37), but not fistula healing. Conclusions In this multicenter study, biologics were associated with bowel restoration and avoidance of proctectomy after fecal diversion without proctectomy for PCD; however, a minority of patients achieved sustained fistula healing after initial fecal diversion or after bowel restoration. These results highlight the refractory nature of PCD.