Duration of postoperative hyperlactatemia has predictive value in recurrent fistula after major definitive surgery for intestinal fistula

Purpose The present study aimed to identify the predictive value of duration of postoperative hyperlactatemia in screening patients at high risk of recurrent fistula after major definitive surgery (DS) for intestinal fistula. Methods If the initial postoperative lactate (IPL) > 2 mmol/L, DS was defined as major definitive surgery. The 315 enrolled patients with major DS were divided into group A (2 mmol/L < IPL ≤ 4 mmol/L), group B (mmol/L < IPL ≤ 6 mmol/L), and group C (IPL > 6 mmol/L). The characteristics of patients were collected, and the duration of postoperative hyperlactatemia was analyzed. According to the occurrence of recurrent fistula (RF), patients were further divided into RF group A, and Non-RF group A; RF group B, and Non-RF group B; and RF group C, and Non-RF group C. Results The duration of postoperative hyperlactatemia was comparable between the RF group A and the Non-RF group A [12 (IQR: 12–24) vs 24 (IQR: 12–24), p = 0.387]. However, the duration of hyperlactatemia was associated with RF in group B (adjusted OR = 1.061; 95% CI: 1.029–1.094; p < 0.001) and group C (adjusted OR = 1.059; 95% CI: 1.012–1.129; p = 0.017). In group B, the cutoff point of duration of 42 h had the optimal predictive value (area under ROC = 0.791, sensitivity = 0.717, specificity = 0.794, p < 0.001). In group C, the cutoff point of duration of 54 h had the optimal predictive value (area under ROC = 0.781, sensitivity = 0.730, specificity = 0.804, p < 0.001). Conclusion The duration of postoperative hyperlactatemia has a value in predicting RF in patients with an IPL of more than 4 mmol/L after major definitive surgery for intestinal fistula.

Duration of Postoperative Hyperlactatemia Has Predictive Value in Recurrent Fistula After Major Definitive Surgery for Intestinal Fistula

Purpose The present study aimed to identify the predictive value of duration of postoperative hyperlactatemia in screening patients at high risk of recurrent fistula after major definitive surgery(DS) for intestinal fistula. Methods If the initial postoperative lactate(IPL)> 2 mmol/L, DS was defined as major definitive surgery. The 315 enrolled patients with major DS were divided into group A (2 mmol/L<IPL≤ 4 mmol/L), group B (mmol/L<IPL≤ 6 mmol/L), and group C (IPL>6 mmol/L). The characteristics of patients were collected, and the duration of postoperative hyperlactatemia was analyzed. According to the occurrence of recurrent fistula (RF), patients were further divided into RF group A, and Non-RF group A; RF group B, and Non-RF group B; and RF group C, and Non-RF group C. Results The duration of postoperative hyperlactatemia was comparable between the RF group A and the Non-RF group A [12 (IQR:12-24) vs 24 (IQR:12-24), p=0.387]. However, the duration of hyperlactatemia was associated with RF in group B (adjusted OR= 1.061; 95%CI: 1.029-1.094; p<0.001) and group C (adjusted OR=1.059; 95%CI: 1.012-1.129; p=0.017). In group B, the cutoff point of duration of 42 hours had the optimal predictive value (area under ROC=0.791, sensitivity=0.717, specificity =0.794, p<0.001). In group C, the cutoff point of duration of 54 hours had the optimal predictive value (area under ROC=0.781, sensitivity=0.730, specificity =0.804, p<0.001). Conclusion The duration of postoperative hyperlactatemia has a value in predicting RF in patients with an IPL of more than 4 mmol/L after major definitive surgery for intestinal fistula.

Nematode as a Cause of Appendicular–Cutaneous Fistula

BackgroundCutaneous fistula may develop spontaneously as a complication of an perforating appendicitis. However, intestinal fistula caused by parasites is a rare report.Case presentationIn the operation, we found that expanded appendix was perforated from its distal part and was fistulized to the right lateral abdominal wall. The complications of postoperative was intestinal fistula. Colonoscopy was performed revealing some nematode around the appendiceal orifice. The development of fistula after bowel resection and anastomosis can be devastating. Immediate drainage and establishment of enteral nutrition can lead to spontaneous healing of fistula.ConclusionsTesting for nematode infection in a patient with suspected appendicitis is not routine, it still stands as a challenge in clinical practice. In view of this situation, killing parasites is necessary, otherwise it is difficult to cure.

Late-Onset Ileocutaneous Fistula Eight Years After Plug Repair With Polypropylene Mesh: A Case Report

Introduction: As one of the short-term complications after inguinal hernia repair, mesh infection frequently occurs but rarely leads to ileocutaneous fistula. We present a rare case of ileocutaneous fistula 8 years after inguinal hernia plug repair with polypropylene mesh.Case Presentation: The patient was a 67-year-old male who underwent a plug repair with polypropylene mesh of the right inguinal hernia. Eight years after the primary repair, skin ulceration with pus presented in the right groin area, and the final diagnosis was enterocutaneous fistula. According to laparoscopic exploration, the ileum below the fistula closely adhered to the abdominal wall. After gently separating the bowel loop, a defect area of about 2 × 3 cm was observed on the surface of the ileum. In laparotomy, the plug was found embedded in the ileum and then was completely removed, and an ileum side-to-side anastomosis was performed. The patient was discharged 2 weeks after the surgery, and follow-up at the sixth month revealed complete healing of the wound and no evidence of hernia recurrence.Conclusion: Late-onset ileocutaneous fistula should be considered in the differential diagnosis in patients who present inflammation and abscess formation after hernia repair. Besides, for patients with suspected intestinal fistula after hernia repair, laparoscopic exploration should be given priority, and the mesh removal approach should be tailored according to the results of laparoscopic exploration.

The Treatment Efficacy of Transparasacral Approach For Presacral Tumor: A Single Center Experience

Background: Presacral tumors, also known as retrorectal tumors, locate in the presacral space and are clinically rare and the approaches for the diagnosis and treatment of presacral tumors are still deficient. The four accepted surgical approaches for presacral tumors include transabdominal approach, sacrococcygeal approach, perineal approach, and combined approach. This study aims to evaluate the treatment efficacy of transparasacral approach for presacral tumors.Methods: 23 patients (7 males and 16 females) who are diagnosed with presacral tumors and receive surgery in transsacral approach at our department were chosen. The gender, age, body mass index (BMI), and clinical symptoms were recorded. The clinical data, postoperative complications, and short and long-term rehabilitation data were recorded and analyzed. Results: The surgery was performed smoothly and the patients recovered well without signs of intestinal fistula, abdominal and pelvic infection, lung infection, organ dysfunction, or organ failure. The incision edema occurred in only one patient. In terms of the histopathological types, presacral tumors can be classified into tailgut cyst (n=10), epidermoid cyst (n=5), teratoma (n=3), and lipoma (n=10). One patient diagnosed with tailgut cyst was accompanied by adenocarcinoma transition. Tumor recurrence didn’t occur in any patients. In addition, no patients complained about dysuria, sacrococcygeal sensory disturbance, or sacrococcygeal and perineal discomfort.Conclusions: Surgical resection with transparasacral approach is effective for the treatment of presacral tumors with the advantages of high safety, good treatment efficacy, few complications, good oncological prognosis, and fast recovery.

Difficult cases of differential diagnosis of acute appendicitis

Despite the results of technological progress in medicine, which has made high-resolution methods of medical imaging available, the problem of differential diagnosis of acute appendicitis does not lose its’ relevance. This can be explained by the fact that the symptoms of acute appendicitis are variable, non-specific, and can mimic other diseases with similar symptoms.Three cases of rare diseases of the gastrointestinal tract that simulates acute appendicitis were presented. Those are primary torsion of the greater omentum with necrosis, caecum cancer with lengthy necrosis in a young patient and Crohn's disease that simulates appendicular infiltrate. All patients underwent surgery. Signs of acute appendicitis were indications for surgery. Laparoscopic resection of greater omentum was performed in the first case. In the second case caecum necrosis with peritonitis was revealed by laparoscopy. Conversion laparoscopy to laparotomy was performed. Caecum necrosis with caecum wall perforation and necrosis of terminal part of the ileum was diagnosed. right hemicolectomy with ileo-transverso anastomosis was carried out. Complicated case of Crohn’s disease was suspected. Nevertheless, the diagnosis of colorectal cancer is established by pathomorphology only. This case is interesting because of rare complication of colon cancer – the caecum and the ileum wall necrosis that was manifestation of the disease. In the third case of Crohn’s disease in a young patient the diagnosis of appendicular infiltrate and surgical policy were wrong. At the first laparotomy by McBurney was performed. A dense infiltrate was found in the right iliac fossa. The intervention was finished by local abdominal package. In the early postoperative period an intestinal fistula was formed. The patient underwent relaparotomy and right hemicolectomy with ileo-transversal anastomosis was carried out. Despite the diagnosis of Crohn's disease was questionable patomorphology and was established after half a year only by colonoscopy. The presented cases illustrate the complexity of acute appendicitis and the importance of modern approaches to diagnosis: irreplaceability of laparoscopy and the feasibility of using diagnostic scales. When the right diagnosis is not clear the intervention might be late for using methods of instrumental diagnostics.

Prevalence of Sarcopenia and Its Effect on Postoperative Complications in Patients with Crohn’s Disease

Background and Aims. Sarcopenia is a prognostic factor of outcomes for various diseases, but reports on sarcopenia in patients with Crohn’s disease (CD) are few. We aim to determine the prevalence of sarcopenia and assess the role of sarcopenia in postoperative complications in patients with CD at a tertiary referral center. Methods. Patients who underwent intestinal surgery for CD from January 2013 to October 2019 were retrospectively enrolled. The L3 skeletal muscle mass index (SMI) was used to identify sarcopenia. Demographic data, preoperative laboratory data, surgical details, and hospital outcomes were recorded. The factors associated with postoperative complications were evaluated through univariate and multivariate analyses. Results. One hundred and twenty-four patients were enrolled. Thirty-four of them (27.4%), including 11 males, were diagnosed with sarcopenia. Compared with patients without sarcopenia, sarcopenic patients had a significantly lower BMI ( P < 0.001 ); lower preoperative serum albumin ( P = 0.006 ), prealbumin ( P = 0.030 ), and hemoglobin levels ( P < 0.001 ); longer hospital stay ( 34.4 ± 26.8 days vs. 22.8 ± 15.6 days, P = 0.003 ); and more occurrences of complications (41.2% vs. 23.3%, P = 0.049 ). The overall incidence of postoperative complications was 28.2%. Infection (51.4%) and intestinal fistula (22.9%) were the most common among such complications. Through the multivariate analysis, sarcopenia was identified as an independent risk factor for major postoperative complications ( odds ratio = 3.974 , 95 % CI = 1.171 –13.489, P = 0.027 ). Conclusion. Sarcopenia is common in patients with CD requiring bowel resection, and it significantly increases the risk of major postoperative complications.