Fistulas and sinus tracts: radiographic evaluation, management, and outcome

Endoscopic Closure of Gastrointestinal Fistulae and Leaks

The development of new endoscopic techniques, such as gastrointestinal (GI) stenting, full-thickness suturing, clip application, and use of tissue adhesives, has had a significant impact on management of GI fistulae. These techniques have shown promising results, but further study is needed to optimize the efficacy of long-term closure. The advancement of endoscopic techniques, including the use of the lumen apposing metal stent (LAMS), has allowed for the deliberate creation of fistula tracts to apply endoscopic therapy that previously could not be achieved. This article examines the rapidly evolving area of endoscopic fistula closure and its relationship to LAMS.

Placental Membranes for Management of Refractory Cutaneous Sinus Tracts of Surgical Origin: A Pilot Study

Despite advances in surgical technique, postoperative complications may lead to refractory cutaneous sinus tracts or tunnels. Negative pressure wound therapy is difficult to apply in longer tracts with a narrow diameter opening and conservative treatment failures ultimately necessitate surgical revisions. The aim of this pilot study was a clinical utility assessment of two different commercial placental membrane products for refractory cutaneous sinus tracts of surgical origin. Patients were treated with viable cryopreserved placental membrane (vCPM, n = 6) or devitalized dehydrated amnion/chorion membrane (dHACM, n = 6). The primary outcome measurement was the proportion of complete sinus tract depth resolution without exudate. Secondary endpoints included 4-week percent reduction in sinus tract probing depth and peri-tract wound surface area, days and number of grafts to resolution, number of wound-related infections, and 1-year recurrence rate for closed sinus tracts. All vCPM patients demonstrated complete sinus tract resolution compared to zero closures in the dHACM group (p = 0.00216). The vCPM group achieved greater percent reduction in probing depth (73.3 ± 21.9 versus −4.4 ± 91.3) and surrounding wound surface area (34.8 ± 86.8 versus −279.3 ± 454.9) at 4 weeks than dHACM. The use of viable intact cryopreserved placental membrane has demonstrated positive clinical outcomes for the treatment for refractory exudative sinus tracts and may be an alternative to repeat surgical intervention.

Radiography of Pressure Ulcers

In patients with longstanding and/or deep pressure ulcers radiology is usually consulted. Survey radiography and sinography in 14 patients with pressure ulcers (6 over the tuber ischii and 8 over the femoral trochanter) were evaluated. Osteomyelitic involvement of adjacent bone was revealed in 9 patients on survey radiography. However, it was usually impossible to assess whether or not bony involvement represents healed or active osteomyelitis. Sinography did not contribute to the assessment of whether or not adjacent cortical bone was involved. However, when a fistulation to an adjacent joint was revealed this contributed substantially to the preoperative planning of resection. We therefore recommend that survey radiography and sinography should be included in the evaluation of these patients but that the results from such examinations are critically evaluated. Joint involvement should be taken seriously as progression of septic arthritis usually occurs rapidly.

An interesting fistula tract presenting with recurrent gluteal abscess: instructive case

A fistula extending from the gluteus to penis is an extremely rare entity. In this paper, we have highlighted novel variant of congenital penile to gluteal fistula complicated with gluteal and penoscrotal abscess in a previously healthy boy. A fistulous tract extending from the gluteus to penis has been shown by fistulogram. Bleomycin has been used in fistula tract with successful results in our patient.

Role of fistulography in evaluating pancreatic fistula after pancreaticoduodenectomy

OBJECTIVE

To evaluate the usefulness of fistulography as a diagnostic and management tool for clinically suspected pancreatic fistulas (PF) after pancreaticoduodenectomy (PD).

METHODS

84 consecutive fistulographies were performed for clinical suspicion of PF and retrospectively analysed. We radiologically defined two types of PF by means of fistulography, PF1 in the case of primary filling with contrast agent of the jejunal loop or stomach and PF2 in the case of secondary filling of the jejunal loop or stomach through a fistulous tract or a fluid collection.

RESULTS

In 35/84 (41.7%) of the fistulograms, a PF1 was demonstrated owing to an instantaneous opacification of the intestinal lumen or the stomach, without evidence of a fistulous tract or fluid collection. In 49/84 (58.3%) fistulograms, a PF2 was demonstrated by the depiction of a fluid collection and/or a fistulous tract and a communication with the intestinal loop or the stomach anastomised with the pancreas. The mean healing time of a PF after PD was 2.7 days for PF1, and 9.8 days for PF2.

CONCLUSION

Fistulography helps in the confirmation of clinically suspect PF, and can distinguish PF1 and PF2, thus decreasing post-operative morbidity significantly.

Radiographic and endoscopic diagnosis and treatment of enterocutaneous fistulas

The management of enterocutaneous fistulas continues to be a challenging postoperative complication. Understanding the anatomy of the fistula optimizes its evaluation and management. Diagnostic radiology has always played an important role in this task. The use of plain radiography with contrasted studies and fistulograms is well documented in the earliest investigations of fistulas and they continue to be helpful techniques. The imaging techniques have evolved rapidly over the past 15 years with the introduction of cross-sectional imaging, ultrasound and endoscopy. The purpose of this chapter is to review both the diagnostic and therapeutic roles of fistulograms, small bowel follow-through, computed tomography, magnetic resonance imaging, ultrasound, and endoscopy in the setting of acquired enterocutaneous fistulas.

High-output fistula

Despite improvements in healthcare delivery, mortality rates for high-output fistulae remain unchanged. The pathophysiology and causes of fistulae are reviewed in this article. An overview of the diagnostic procedures to delineate fistulae and underlying bowel disease together with their complications is included. Management of high-output fistulae consists of assessment and stabilization of patients, followed by conservative management by a multidisciplinary team until spontaneous or surgical closure of fistulae.

Acquired gastrointestinal fistulas: classification, etiologies, and imaging evaluation

Fistulas are abnormal communications between two epithelial-lined surfaces. Gastrointestinal fistulas encompass all such connections that involve the alimentary tract, and they can be congenital or acquired in nature. This review focuses on acquired gastrointestinal fistulas. Development of an acquired gastrointestinal fistula can greatly affect patient outcome, yet the clinical manifestations are often protean in nature and the etiology, elusive. Imaging plays an important role in the detection and management of acquired gastrointestinal fistulas. The more routine use of cross-sectional imaging (especially computed tomography and magnetic resonance imaging) has altered the standard sequence of radiologic evaluation for possible fistulas, but fluoroscopic studies remain a valuable complement, especially for confirming and defining the anomalous communications. In this review, a classification scheme for gastrointestinal fistulas is provided, major causes are discussed, and individual fistula types are elaborated with an emphasis on contemporary imaging approaches.

The role of endoscopy in the evaluation of fistulizing Crohn's disease

Fistulas in Crohn's disease are classified as internal fistulas, for example, enteroenteric, enterovesical, rectovaginal, and external fistulas, for example, enterocutaneous, perianal, and parastomal. Although radiographic contrast studies are superior to endoscopy for diagnosing fistulas, endoscopic procedures have a definite role in the evaluation and management of fistulizing Crohn's disease. Endoscopy allows for tissue sampling, and provides information regarding the extent and severity of gastrointestinal inflammation, and the presence of such complications as strictures and cancer. Preoperative colonoscopy has particular value in assessing an enterocolonic fistula, and has important implications regarding the type of surgery performed. Endoscopic therapy for Crohn's fistula is less certain, but may allow for dilation of associated strictures, and may someday serve as a better delivery system for targeted anticytokine and immunologically based therapy.

Radiologic and endoscopic diagnosis of Crohn's disease

This article reviews the radiologic and endoscopic diagnosis of Crohn's disease. Radiographic and endoscopic findings of Crohn's disease are discussed; a practical approach to the selection of radiologic modalities is presented; and the role of endoscopy in diagnosis and treatment is explained.

Colour Doppler ultrasound in vesicovaginal fistulas

The purpose was to evaluate the feasibility of diagnosing vesicovaginal fistulas by colour Doppler ultrasound with contrast media. Twelve consecutive patients were examined by vaginoscopy, methylene blue test, cystogram and cystoscopy. For ultrasound examination, the bladder was filled with saline. Then diluted contrast media (Levovist) was instilled. Colour Doppler ultrasound revealed a jet phenomenon through the bladder wall toward the vagina, proving the existence of the fistula. Eleven patients had vesicovaginal fistulas, one patient a vesicoureterovaginal fistula. Colour Doppler ultrasound had correct results in 11 of 12 patients (92%). In follow-up examinations of four patients during a prolonged drainage of the bladder, we could correctly demonstrate the closure of one fistula. Colour Doppler ultrasound with contrast media is a new useful diagnostic tool in the evaluation and follow-up of vesicovaginal fistulas. It is less invasive than cystoscopy and needs no radiation exposure. The examination is well tolerated by the patients.

Current CT/MRI examination of the lower intestinal tract

For evaluating primary colonic and rectal malignancies, CT and MRI are often complementary imaging methods which are useful in assessing patients suspected of having extensive disease and in deciding whether a patient will benefit from preoperative radiation. CT is also helpful in designing radiation ports and in detecting complications related to the neoplasm such as perforation with abscess formation. MRI offers excellent tissue resolution which aids in distinguishing between localized colorectal disease and disease which invades muscle. Also, MRI can add information with coronal views for determining whether a sphincter-saving procedure can be performed, and may be of benefit for assessing the subtle extent of tumour into muscle and bone. However, CT and MRI lack the ability to assess depth of neoplastic involvement within bowel wall. This limitation is the major factor which, combined with the inability to diagnose metastatic tumour foci in normal-sized nodes and microinvasion of perirectal fat, prevents optimal tumour staging. Because of the low accuracy for assessing early cancer stages, neither CT nor MRI are recommended for routine use in preoperative staging. CT and MRI have a premier role in the assessment of recurrent colorectal neoplasm, with CT providing a slightly better overall evaluation due to volume imaging, easy image reconstructions in different planes, and availability of excellent oral and intravenous contrast agents. Cross-sectional imaging is the only method to evaluate fully patients with total AP resection, particularly male patients. Neither CT nor MRI can determine with certainty that a soft tissue density in the surgical bed following total AP resection represents recurrent tumour unless a clear mass is present which has increased in size over time. However, both methods surpass colonoscopy for detecting early mass-like tumour recurrence at the anastomotic site due to its extrinsic component. Cross-sectional imaging plays a prominent role in assessing inflammatory disease of the colon. Clinical history, laboratory data and extent of involvement are used together with results from radiographic examinations to reach a specific diagnosis. CT is preferred over MRI in the assessment of extent of inflammatory disease in and beyond the bowel wall. An additional benefit of CT over MRI is the fact that patients with abscesses or large fluid collection can undergo drainage while still in the CT scanner. CT and MRI can aid in the distinction between ulcerative colitis with minimal wall-thickening and Crohn's disease with marked wall-thickening combined with skip lesions and fistula and/or abscess formation.(ABSTRACT TRUNCATED AT 400 WORDS)

Nephrocutaneous fistula diagnosed by computed tomography

We present an unusual case of isolated nephrocutaneous fistula secondary to renal calculi with perirenal infection. The usefulness of computed tomography (CT), with its depiction of the extent of involvement and its characterization of the disease process, is described and the literature is reviewed.