The Promise and Neglect of Follow-up Care in Obstetric Fistula Treatment in Uganda

Considered the most severe of maternal morbidities, obstetric fistula is a debilitating childbirth injury that results in complete incontinence with severe physical and psychosocial consequences.The primary intervention for women with obstetric fistula is surgical repair, and success rates for repair are reported between 80% and 97%. However, successful treatment is commonly defined solely by the closure of the fistula defect and often fails to capture women who continue to experience urinary incontinence after repair. Residual incontinence post-fistula repair is both underreported and under-examined in the literature. Through a novel mixed-method study that examined clinical, quantitative, and qualitative aspects of residual incontinence post-repair, this chapter draws on in-depth interviews with women suffering with residual incontinence and fistula surgeons, participant observation, and a desk review of fistula policies and guidelines to argue that an inadequate model of fistula treatment that neglects follow-up care exists. We found that obstetric fistula policy has been determined in large part over the years by international development agencies and funding organizations, such as international nongovernmental organizations (INGOs). We argue that the neglect in follow-up care is evident in fistula policy and can be traced to a donor-funded treatment model that fails to prioritize and fund follow-up care as an essential component of fistula treatment, instead focusing on a “narrative of success” in fistula treatment. As a result, poor outcomes are underreported and women who experience poor outcomes are largely erased from the fistula narrative. This erasure has limited the attention, resources, research, and dedicated to residual incontinence, leaving out women suffering from residual incontinence largely without alternative treatment options.

Endoluminal vacuum therapy in the management of an esophago-pleural fistula as a complication of Boerhaave syndrome in a patient with eosinophilic esophagitis

Background Boerhaave syndrome is an uncommon condition that represents about 15% of all esophageal perforation. A subset of these patients has eosinophilic esophagitis, a chronic inflammatory disease of the esophagus, that carries a risk of perforation of about 2%. Esophageal perforations can rarely result in the development of an esophago-pleural fistula. Treatment of esophago-pleural fistula represent a challenge due to lack of high quality evidence and scarce reported experience. Endoluminal vacuum-assisted therapy could have a role in the management by using the same principle applied in external wounds which provide wound drainage and tissue granulation. Case presentation We report a unique case of a 24-year-old man with eosinophilic esophagitis complicated with an esophageal rupture who developed an esophago-pleural fistula and was successfully managed with a non-surgical approach using endoluminal vacuum-assisted therapy. To our knowledge this could be the first experience reported in a patient with eosinophilic esophagitis. Conclusion Endoluminal vacuum-assisted therapy might be an effective and novel strategy in patients with eosinophilic esophagitis and esophago-pleural fistula as a consequence of Boerhaave syndrome. Appropriately designed studies are required.

Choledochoduodenal fistula: a rare complication of acute peptic ulcer bleeding

A 75-year-old man presented with a 3-week history of melaena and right upper quadrant pain. This was on a background of significant alcohol intake and a complex medical history. He was haemodynamically unstable with investigations indicating a new iron-deficiency anaemia. After resuscitation, urgent intervention was required under general anaesthesia. This involved a triple phase abdominal CT, followed by emergency oesophagogastroduodenoscopy. This revealed deep ulceration with extension to the pancreatic head and common bile duct. There was also evidence of pneumobilia on CT, secondary to a choledochoduodenal fistula. Treatment encompassed an invasive and medical approach. Following treatment, the patient was stable, with follow-up endoscopy exhibiting good duodenal mucosal healing.

Sphincter Preserving Techniques in Anal Fistula Treatment

Complex anal fistulas present a challenge to even a seasoned colorectal surgeon due to high rate of recurrence and a real possibility of fecal incontinence if treated with conventional methods (e.g., fistulotomy, fistulectomy, seton placement). Although the illness is benign in nature, it can significantly decrease patient’s quality of life because of symptoms like pain and soiling. Given those facts, minimally invasive or sphincter preserving methods of treatment were introduced. Some of these include: Video-assisted anal fistula treatment (VAAFT), ligation of intersphincteric fistula tract (LIFT), Fistula-tract laser closure (FILAC), rectal advancement flap (RAF), treatment with platelet cells and combinations of techniques. This chapter would be an overview of these novel techniques with reference to latest clinical trials and meta-analyses.

The effect of aortic esophageal fistula treatment after TEVAR with artificial vessel bypass（Single center clinical experience）

Objective: To investigate the effect of aortic esophageal fistula treatment after thoracic aortic endovascular repair (TEVAR) with artificial vessel bypass. Methods: The clinical data of 6 consecutive patients who received surgical treatment at Shanghai Deda Hospital from September 2019 to June 2021 due to aortic esophageal fistula after TEVAR were retrospectively analyzed. There were 6 males, aged (47.7±8.2) years old (range: 35-56 years old). All patients had recurrent fever, and 4 patients had positive blood cultures. According to the specific conditions of the patients, all patients underwent artificial blood vessel bypass and jejunostomy under general anesthesia without extracorporeal circulation. One case underwent artificially infected vascular segment resection and esophageal repair at the same time. 5 cases underwent artificial infection vascular resection, 4 of them underwent esophageal repair, and 1 case had a large intraoperative fistula and local resection of the esophagus. Sensitive antibacterial drugs were continued after the operation for 6 to 8 weeks. Results: There were 2 deaths in hospital, 1 case of large cerebral infarction early postoperatively, and 1 case of septic shock. The remaining 4 patients recovered well after the operation and were discharged. The follow-up period was 2 to 23 months. During the follow-up period, the remaining patients had no recurrence of infection and esophageal fistula. Conclusion ：In patients with aortic esophageal fistula after TEVAR, the establishment of artificial vascular bypass, the resection of the infected vascular segment, contemporaneous or staged esophageal repair, regular anti-infective treatment can obtain a good prognosis.

Video-assisted anal fistula treatment versus fistulectomy and sphincter repair in the treatment of high cryptoglandular anal fistula: a randomized clinical study

Background Video-assisted anal fistula treatment (VAAFT) may have a recurrence rate comparable to that of fistulectomy and sphincter repair (FSR) in the treatment of high anal fistula and with potential advantages in wound healing, functional outcome and quality of life. The aim and objectives of the study are to compare the outcome of VAAFT with that of FSR for high cryptoglandular anal fistula. Methods This was a single-centre randomized controlled trial of adults with high anal fistula comparing FSR with VAAFT. Primary outcome was fistula recurrence. Secondary outcomes were results of anal manometry, quality of life and faecal continence. A power calculation of 33 patients in each arm (1 : 1) was based on recurrence in the FSR and VAAFT groups of 5 per cent and 30 per cent respectively. Follow-up at 6 months after surgery included physical examination, MRI, anal manometry, quality-of-life assessment (RAND SF 36 questionnaire) and faecal-continence assessment (Wexner score). Results The study was terminated early due to high recurrence rates in both groups. A total of 45 patients were included. Recurrence rates were 65 per cent for VAAFT and 27 per cent for FSR, with hazard ratio 4.18 (P = 0.016). Length of the fistula was a risk factor with an association with recurrence (hazard ratio 1.8, P = 0.020). There were significant differences in quality of life in favour of FSR and in anal manometry in favour of VAAFT with a significant improvement in Wexner score in both groups. Conclusion FSR was associated with a lower recurrence rate than VAAFT in the management of complex anal fistulae in this single-centre study but the study was terminated early due to higher than predicted recurrence rate in both groups. Registration number NCT02585167 (http://www.clinicaltrials.org).

Evaluation of Fistulotomy with Immediate Sphincteric Reconstruction in the Treatment of High Transsphincteric Perianal Fistula

Background High perianal fistula treatment remains challenging, mainly due to the variability in success and recurrence rates as well as continence impairment risks. So far, no procedure can be considered the gold standard for surgical treatment. Yet, strong efforts to identify effective and complication-free surgical options are ongoing. Fistulotomy can be considered the best perianal fistula treatment option, providing a perfect surgical field view, allowing direct access to the source of chronic inflammation. Controversy exists concerning the risk of continence impairment associated with fistulotomy. The present study aimed to assess the outcomes of fistulotomy with immediate sphincteric reconstruction regaring fistula recurrence, incontinence, and patient satisfaction. Methods This interventional study was performed at the General Surgery Department of Zagazig University Hospital during the period from July 2018 to December 2019 on 24 patients with a clinical diagnosis of high transsphincteric fistula-in-ano. The fistulous tract was laid open over the probe placed in the tract. After the fistula tract had been laid open, the tract was curetted and examined for secondary extensions. Then, suturing muscles to muscles, including the internal and external sphincters, by transverse mattress sutures. Results Our study showed that 2 patients develop incontinence to flatus ∼ 8.3%.and only one patient develop incontinence to loose stool, 4.2%. Complete healing was achieved in 83% and recurrence was 16.6%. Conclusion Fistulotomy with immediate sphincteric reconstruction is considered to be an effective option in the management of high perianal fistula, with low morbidity and high healing rate with acceptable continence state.

Building a Country-Wide Fistula Treatment Network in Kenya: Results From the First Six Years (2014-2020)

It is estimated that one million women worldwide live with untreated fistula, a devastating injury primarily caused by prolonged obstructed labor when women do not have access to timely emergency obstetric care. Women with fistula are incontinent of urine and/or feces and often suffer severe social and psychological consequences such as profound stigma and depression. Obstetric fistula affects economically vulnerable women and garners little attention on the global health stage. Exact figures on fistula incidence and prevalence are not known. In Kenya, results from a population-based survey suggest that approximately 120,000 reproductive-aged women have experienced fistula-like symptoms.In 2013, Fistula Foundation designed a program to significantly increase country-wide fistula treatment capacity in Kenya by addressing key barriers that limit women’s ability to receive treatment. Launched as Action on Fistula, and later becoming the Fistula Treatment Network, this model created a network of hospitals, a training center for surgeons and healthcare providers, and robust community outreach and reintegration activities. The Fistula Treatment Network was implemented by Fistula Foundation in collaboration with the Ministry of Health and Kenyan non-governmental and community-based organizations. Fistula Foundation and its donors provided the program’s funding, with seed funding, representing about 30% of the program budget, provided by Astellas Pharma EMEA.Over a six-year period, 2014-2020, the network supported 6,223 surgeries at seven hospitals, established a fistula training center and trained eleven surgeons, trained 424 Community Health Volunteers, conducted extensive outreach to all 47 counties in Kenya, and contributed to the National Strategic Framework to End Female Genital Fistula. At 12 months post fistula repair, 96% of women in a community setting reported that they were dry and not experiencing any incontinence and the proportion of women reporting normal functioning increased from 18% at baseline to 85% at twelve-months. The Fistula Foundation’s Fistula Treatment Network model increased access to fistula care services, strengthened the healthcare workforce, improved understanding of fistula and reduced stigma in a community setting. This integrated approach is an effective and replicable model for building capacity to deliver comprehensive fistula care services in other countries where the burden of fistula is high.

Consequences of Obstetric Fistula: Lived Experiences of Fistula Patient Women in Jimma University Medical Center, Southwest Ethiopia.

Background: Women in low-income countries, including Ethiopia, experience delays in seeking treatment and suffer from obstetric fistula and its consequences. To assess the consequences of obstetric fistula among women who were patient of the problem in Jimma University Medical Center, Southwest Ethiopia. Methods: An exploratory study was conducted among 24 women receiving obstetric fistula treatment from April 01-30, 2019 at Jimma University Medical Centre. Data were collected by in-depth interviews. Data analysis was done by using thematic framework analysis.Results: Most women with obstetric fistula face various physical challenges such as pain, body weakness, and numbness of legs. They also face various psychosocial problems such as humiliation, stigma, and discrimination, inability to participate in social events, divorce, stress, depression, and suicidal ideation. Conclusion: Obstetric fistula exerts tremendous physical, emotional, financial, and social trauma on those affected. So, strengthening the existing fistula care and integrate psycho-social and economic support is very crucial.