Treatment-seeking for vaginal fistula in sub-Saharan Africa

BACKGROUND

There is dearth of data regarding the treatment-seeking practice of women living with vaginal fistula. The paper describes the health-seeking behaviour of fistula cases in the sub-Saharan Africa (SSA) where the burden of the problem is high.

METHODS

The data of 1,317 women who ever experienced fistula-related symptom were extracted from 16 national Demographic and Health Surveys carried out in SSA between 2010 and 2017. The association between treatment-seeking and basic socio-demographic characteristics was analysed via mixed-effects logistic regression and the outputs are provided using adjusted odds ratio (AOR) with 95% confidence intervals (CI).

RESULTS

Among all women who had fistula-related symptom, 67.6% encountered the problem soon after delivery, possibly implying obstetric fistula. Fewer identified sexual assault (3.8%) and pelvic surgery (2.7%) as the underlying cause. In 25.8% of the cases clear-cut causes couldn't be ascertained and, excluding these ambiguous causes, 91.2% of the women possibly had obstetric fistula. Among those who ever had any kind of fistula, 60.3% (95% CI: 56.9-63.6%) sought treatment and 28.5% (95% CI: 25.3-31.6%) underwent fistula-repair surgery. The leading reasons for not seeking treatment were: unaware that it can be repaired (21.4%), don't know where to get the treatment (17.4%), economic constraints (11.9%), the fistula healed by itself (11.9%) and feeling of embarrassment (7.9%). The regression analysis indicated, teenagers as compared to adults 35 years or older [AOR = 0.31 (95% CI: 0.20-47)]; and women without formal education compared to women with formal education [AOR = 0.69 (95% CI: 0.51-0.93)], had reduced odds of treatment-seeking. In 25.9% of the women who underwent fistula-repair surgery, complete continence after surgery was not achieved.

CONCLUSION

Treatment-seeking for fistula remains low and it should be improved through addressing health-system, psycho-social, economic and awareness barriers.

Double J Stents in the Treatment of Gynaecological Injury to the Ureter

Ureteric injury is a recognized complication of hysterectomy and may present with obstruction or fistula.

Between 1987 and 1989 in Oxford nine patients with 10 injured ureters underwent attempted retrograde placement of double J stents. Three patients had successful outcomes and one patient with bilateral ureteric obstruction required reimplantation of the right ureter after successful stenting of the left ureter. One patient required removal of a stent due to irritation but her fistula eventually closed. In three patients placement was unsuccessful and in one patient injury to the bladder base prevented the ureteric orifices from being seen and hence stenting was not possible. Thus five of these 10 injured ureters were managed successfully with double J stents.

We advocate the initial use of double J stents in gynaecological ureteric injury. This approach is simple and may cure the fistula. If it is unsuccessful, subsequent reimplantation is not hindered.

First-in-Human Case Study: Pregnancy in Women With Crohn's Perianal Fistula Treated With Adipose-Derived Stem Cells: A Safety Study

The aim of this study was to determine whether treatment with adipose-derived stem cells (ASCs) had any influence on fertility, course of pregnancy, newborn weight, or physical condition of newborns. We performed a retrospective study of patients with a desire to become pregnant after having received intralesional injection of autologous ASCs for the treatment of perianal or rectovaginal fistula associated with Crohn's disease. We collected data on the resulting pregnancies, deliveries, and newborns of these patients. ASCs were expanded in vitro and characterized according to the international guidelines for cell surface markers (clusters of differentiation) and differentiated to adipocytes, chondrocytes, and osteocytes prior to implantation (except first implant in 2002). We analyzed five young women with Crohn's disease treated with ASCs: one for rectovaginal and perianal fistula, two for rectovaginal fistula only, and two for perianal fistula only. All patients received 2 doses of 20 million and 40 million cells at an interval of 3-4 months. Another patient received 2 doses of 6.6 million and 20 million ASCs with 9 months between each dose. Fertility and pregnancy outcomes were not affected by cell therapy treatment. No signs of treatment-related malformations were observed in the neonates by their respective pediatricians. In the patients studied, cell therapy with ASCs did not affect the course of pregnancy or newborn development.

SIGNIFICANCE

Local treatment with mesenchymal stem cells derived from adipose tissue seems not to affect the ability to conceive, the course of pregnancy, pregnancy outcomes, or newborns' health in female patients. This is the first publication about pregnancy outcome in women with perianal fistula and Crohn's disease treated with stem cell therapy, and could be of interest for doctors working in cell therapy. This is a very important question for patients, and there was no answer for them until now.

[Gynecology and nursing practice in Ethiopia]

In Africa, many women suffer from the effects of a difficult childbirth. The obstetric fistula, a common condition, leads to suffering and stigmatisation. In this article, a nurse having carried out several humanitarian missions in Africa and the Middle East, shares with us the day-to-day work of Ethiopian nurses who have chosen to devote themselves to helping women affected by this disability.

Genital fistulas in female Crohn's disease patients.: clinical characteristics and response to therapy

BACKGROUND

Genital fistulas (GF) can arise in the course of Crohn's disease (CD), are difficult to manage and determine a significant alteration of the quality of life.

AIMS

To review the joint experience of the Inflammatory Bowel Disease Units in six University Hospitals in the management of GF in Crohn's disease on female patients.

RESULTS

A total of 47 patients with GF were identified, affecting 3.8% of women with CD treated in our centers. A 47.5% of patients were smokers. The median of time from the diagnosis of CD reached 102 months. According to anatomical type, GF were classified as rectovaginal (74.5%), anovaginal/anovulvar (21.3%) and enterovaginal (4.3%). Main symptoms were vaginal discharge of fecal material (55.3%), vaginal passage of gas (40.4%), or both. Fistulas were treated with antibiotics in 59.6% of patients, without any lasting success. Thiopurines were used in 80.9% of cases, with 13.2% of complete and 23.7% of partial responses. Anti TNF-alpha therapy was applied in 63.8%, with a 16.7% of complete and a 30% of partial responses (all responding patients received infliximab). Surgery was indicated in 38.3% of patients, with a 22% of complete responses after a first operation and 38.8% after reintervention. In all, definitive closure after one or more of these therapies was achieved in only 31.9% of cases.

CONCLUSION

Genital fistulas are a significant problem in female Crohn's disease patients. Therapy is not well defined and only partially effective (one in three cases). Surgical therapy stands out as the most effective treatment.

Obstetric fistula: Guiding principles for clinical management and programme development, a new WHO guideline

It is estimated that more than 2 million women are living with obstetric fistulas (OFs) worldwide, particularly in Africa and Asia, and yet this severe morbidity remains hidden. As a contribution to the global Campaign to End Fistula, the World Health Organization (WHO) published Obstetric fistula: Guiding principles for clinical management and programme development, a manual intended as a practical working document. Its 3 main objectives are to draw attention to the urgency of the OF issue and serve as an advocacy document for prompt action; provide policy makers and health professionals with brief, factual information and principles that will guide them at the national and regional levels as they develop strategies and programs to prevent and treat OFs; and assist health care professionals as they acquire better skills and develop more effective services to care for women treated for fistula repair.

The Campaign to End Fistula: what have we learned? Findings of facility and community needs assessments

OBJECTIVE

To present a summary of the findings of the fistula needs assessments that have been conducted through the Campaign to End Fistula in 25 countries in Africa and Asia to expand knowledge on the issue related to causes and impact, country capacity to manage the problem and clinical and programmatic gaps.

METHOD

The methodology of the assessments was qualitative and quantitative, and included focus group discussions; in-depth interviews/narratives; key informant interviews; and review of medical records, with slight variations by country.

RESULTS

Analysis of 20 of these assessments provides insight into the capacities, gaps, and perspectives specific to each country regarding fistula prevention and treatment and the social reintegration of treated women.

CONCLUSION

Needs assessment findings have been key tools to spark action and guide the implementation of national programs to eliminate obstetric fistulas throughout Africa and Asia.

Fistula Fortnight: innovative partnership brings mass treatment and public awareness towards ending obstetric fistula

OBJECTIVE

As part of the global Campaign to End Fistula, the Fistula Fortnight, a 2-week mass obstetric fistula treatment project, was organized in northern Nigeria to contribute to reducing the backlog of untreated fistulas and raise awareness regarding obstetric fistulas and safe motherhood.

METHODS

An array of partners joined forces to provide free surgical treatment, strengthen the capacity of existing facilities to manage obstetric fistulas, and utilize media strategies to raise awareness.

RESULTS

The Fistula Fortnight took place from February 21 to March 6, 2005, at 4 established fistula repair centers in the northern Nigeria states of Kano, Katsina, Kebbi, and Sokoto. A total of 569 women received treatment, with an 87.8% rate of successful closures. The highly publicized event also raised awareness on the issue of obstetric fistula and helped put a face to maternal deaths.

CONCLUSION

The Fortnight, which required extensive and thoughtful planning involving many persons cognizant of health system and quality of care issues, was effective in drawing attention to the vast fistula problem and contributed to reducing the backlog of patients.

USAID program for the prevention and treatment of vaginal fistula

The cornerstone of the US Agency for International Development (USAID) fistula program is to support and strengthen local capacity for fistula repair. The USAID program includes support to upgrade facilities, enhance local surgical repair capability, allocate equipment and supplies to operating rooms, implement quality improvement systems, and cover the women's transportation costs to and from the treatment facilities. The program also offers training in clinical and counseling skills; transferring skills South-to-South; and monitoring and evaluating the program's effectiveness. As new fistula cases continually increase the backlog of untreated cases, its efforts are also directed toward the prevention of fistula and the reintegration of treated women into their communities. Furthermore, the program challenges the culture of sexual violence against women that leads to traumatic gynecologic fistulas.

A community program for women's health and development: Implications for the long-term care of women with fistulas

The Women's Health and Development project, also known as FORWARD, was set up to improve the social, economic, and health status of women affected with vesico-vaginal fistulas. The project takes a holistic approach not only by providing surgical repair and rehabilitation, but also through the development of skills that will help women improve their physical and economic well-being. In addition, to prevent vesico-vaginal fistulas in young women, the project organizes campaigns to bring about a culture fostering the education and empowerment of women. These campaigns also raise awareness on general health, reproductive health and rights, and the necessity of integrating women into mainstream community development programs. In 2006, the project was in its seventh year and still recording success.

Improving community knowledge of obstetric fistula prevention and treatment

In recent years, information has emerged in the scientific literature regarding the experience of physicians and clinical staff who try to prevent and treat obstetric fistulas at health facilities in developing countries. However, little is known about attempts to match the services they provide with policy and programmatic interventions in the communities they serve. To determine what is known about community involvement in the prevention and treatment of obstetric fistulas, the authors inquired into experiments carried out by EngenderHealth and partners in 15 African and Asian countries. From raw data, gray literature, and personal communications with those working in the field, they learned that engaging the community may be the keystone in the eradication of fistulas in low-resource settings, and they learned how to engage the community.

Treatment of anovaginal or rectovaginal fistulas with modified Martius graft

OBJECTIVE

The treatment of ano- or rectovaginal fistula is still difficult. The use of the Martius flap is well described as an adjunctive technique in their repair. We report our experience of a modified Martius flap in the management of ano- or rectovaginal fistula.

METHOD

This is a retrospective study of 14 women presenting with an anovaginal (n = 9) or rectovaginal fistula (n = 5). All were treated by a modified Martius graft. The aetiology included Crohn's disease (n = 7), ulcerative colitis (n = 4), radio-induced (n = 1), obstetric (n = 1) and villous tumour (n = 1).

RESULTS

All 14 fistulas healed within the 3 months after surgery. Subsequently, two patients with Crohn's disease required an abdominoperineal resection owing to progressive anal lesions. Two other patients experienced faecal incontinence which improved with functional rehabilitation treatment.

CONCLUSION

A modified Martius flap is a valuable option in the treatment of ano- or rectovaginal fistula. In the case of Crohn's disease, however, the prognosis depends primarily on subsequent clinical evolution of the condition.

Patch repair of ileoanal pouch-vaginal fistula with Permacol collagen implant

Though uncommon, ileoanal pouch-vaginal fistulas after restorative proctocolectomy present quite a challenge. Multiple salvage procedures, including endoanal, transabdominal, and trans-vaginal, have been used. Because of high recurrence rates, multiple operations are not uncommon, and ultimate pouch failure rates have been reported as high as 45 per cent. The Permacol Collagen Implant is a surgical implant that has been used successfully in a variety of operations ranging from urological to maxillofacial. Its properties allow fibroblast infiltration and revascularization so that it gradually becomes permanently incorporated into the surrounding tissue, providing strength and inhibiting scarring and contraction. We report the first documented case of Permacol use in repair of ileoanal pouch-vaginal fistula and we feel that it warrants further investigation as an option in the treatment of these fistulas.

Eliminating obstetric fistula: progress in partnerships

Obstetric fistula persists in the developing world due to poor access to obstetric care. It has been overlooked in the past, as the women suffering from fistula often live on the fringe of society due to their poverty and the stigma surrounding the condition. A global Campaign to End Fistula is bringing a variety of actors together to raise awareness and support to prevent fistula and provide comprehensive treatment for women living with fistula. This paper describes the strategies and progress of the campaign since it began in 2003.

Colovaginal fistulas. Etiology and management

OBJECTIVE

To review the diagnosis and treatment of colovaginal fistulas from various causes.

DATA SOURCES

Papers on colovaginal fistulas were identified using Ovid and PubMed. The search terms used were as follows: colovaginal fistulas, rectovaginal fistulas, diverticular disease and fistulas.

METHODS OF STUDY

Articles were selected based on their relevance to colovaginal fistulas and were then further subdivided into epidemiology, etiology, presentation, diagnosis and management.

RESULTS

English-language papers were selected based on their relevance to all aspects of colovaginal fistulas.

CONCLUSION

Optimizing nutrition is paramount prior to surgery. Medical management rarely corrects the problem. Diverticular colovaginal fistulas arise in patients who have previously undergone a hysterectomy. Radiation-related fistulas often involve the distal sigmoid colon and rectum, and recurrent cancer must be ruled out. Often symptoms are associated with radiation cystitis and terminal ileitis. When indicated, restoration of intestinal continuity is preferred. Malignant fistulas carry a poor prognosis, and when surgical removal is not practical, they are treated palliatively with fecal diversion or an endoluminal stent. Those arising from inflammatory bowel disease most frequently arise due to Crohn's disease, and extirpation of diseased bowel and associated abscess will successfully treat the condition. Fistulas arising from ulcerative colitis can be malignant. There remains a small role for colostomy as a nondefinitive procedure to alleviate symptoms. Colovaginal fistulas require a multidisciplinary approach and focused diagnostics, successful treatment can dramatically improve the patient's quality of life.

Rotary responds to women's health needs

In working to improve the health of women, particularly in developing countries, governments face a monumental challenge. Limited resources, insufficient training, and poor infrastructure are just some of the obstacles to advancements in the field of female medicine. It is a goal of Rotary International, a worldwide association of service-minded business and professional people, to facilitate efforts to bring medical care to women and girls and to help them to build all-around healthy lives. This article gives background on Rotary International and highlights some of the ways Rotarians are using their resources, their global network, and their professional expertise to advance and promote women's health.

[Uretero-vaginal fistula. Therapeutic alternatives concerning 10 cases]

OBJECTIVE

Our purpose was to study aetiopathogenic, diagnostic and therapeutic aspects of ureterovaginal fistulas.

STUDY DESIGN

A retrospective study concerned 10 ureterovaginal fistulas. The main causes were gyneacoligical and obstetrical procedures. The diagnosis was based on clinical considerations and intravenous pyelography in all cases. Various therapeutic methods were used: Fistulas has managed in three cases by ureteroneocystostomy. Five cases were managed with ipsilateral ureteroureterostomy, the segment of ureter below the fistula was identified using ureteroscopic perforation of this segment in three cases. In one case the fistula was successfully managed by ureteroscopic placement of ureteral stent. In case whose fistula was developed after cancer pelvic we choice abstention.

RESULTS

Late radiology showed success of the procedure in 7 patients and persistance of hypotony in 2 cases treated by u reteroneocystostomy.

CONCLUSION

Ureterofistula is rare, but a relative frequent complication of pelvic surgery whose prevention is the most efficient treatment. Ureteroureterostomy is a good procedure when ureteroscopy is performed.

Posthysterectomy vaginal cuff fistula: diagnosis and management of an unusual cause of "incontinence"

OBJECTIVES

Connection between the vaginal cuff and the peritoneal cavity after hysterectomy is a rare event that can mimic urinary incontinence. The appropriate evaluation and treatment of these patients is discussed.

METHODS

Five patients underwent excision of the vaginal cuff during a 12-month period. All of these patients had a negative workup for urinary incontinence, except for 1 patient who also had stress incontinence and required a vaginal wall sling at the time of cuff excision.

RESULTS

All 5 patients are presently free of excess vaginal drainage or significantly improved, with a mean follow-up of 6 months. One patient developed stress incontinence after cuff excision and later required a vaginal wall sling. There have been no perioperative complications and no evidence of recurrent fistula.

CONCLUSIONS

Fistula of the vaginal cuff is a diagnosis of exclusion after urinary incontinence has been ruled out. A high index of suspicion is often required to make the diagnosis because these patients often present with symptoms highly suggestive of urinary leakage. Fistula of the vaginal cuff is successfully treated with excision of the vaginal cuff and the fistulous tract (if identified), with minimal morbidity.

[Rigid ureteroscopy. Apropos of 88 cases]

Rigid ureteroscopy has become a common tool for the diagnosis and management of several diseases of the upper urinary tract. Between April 1990 and April 1996, 92 ureteroscopy procedures were performed in 88 patients in the B Urology Department of Avicennes hospital for diagnostic or therapeutic purposes. The commonest therapeutic procedure was stone manipulation (72 cases). The overall success rate was 90.8% (Distal ureter: 89.6%, mid ureter: 80%, lumbar ureter: 100%) and the complication rate was 4%. Therapeutic ureteroscopy was also used to dry ureterovaginal fistula (4 cases) and ureteral fistula with retroperitoneal urinoma (2 cases), and to remove a double J stent which had migrated into the pelvic ureter (3 cases). Diagnostic ureteroscopy was performed for 7 ureteral strictures including 3 extrinsic compressions and 4 ureteral strictures all treated with dilatations after biopsy. One false passage was observed among diagnostic ureteroscopy procedures. Rigid ureteroscopy is a minimally invasive and reliable technique for the management of ureteric calculi and for the diagnosis and treatment of other ureteric lesions.

[Genitourinary fistulae at the National Institute of Perinatology]

Evaluation of the characteristics of urogenital fistula with a retrospective study at the clinic of Urology Ginecologica in the Instituto Nacional de Perinatologia between March 1992 to June 1995, information of the location, etiopathogenesis of the disease, urinary tract infection and surgical treatment were obtained form de patients records in the clinic. The etiophatogenesis of the disease was surgical gynecological procedures in 51.1%, and obstetric cause 48.5%; the location were 14 (66.6%) vesicovaginal, 5 (23.5% 0 ureterovaginal and 2 (urethrovaginal). The abdominal approach were in 8 patients and vaginal route in 9, no surgical treatment were 2. Successfully repair fistula were in 80.9%. Urinary tract infections before treatment agreed on the obstetric etiology was 47.6%, and for surgical gynecological procedures 52.2%. There is an increase in the incident of obstetric vesicovaginal fistula, we believe it depends on the patients that we have in de Instituto Nacional de Perinatologia, most of them are obstetric patients.

Genital fistulas secondary to diverticular disease of the colon: a review

Genital fistulas that complicate diverticular disease of the sigmoid colon may no longer be considered esoteric, or even rare phenomena. The vast majority of such lesions present with a foul, often fecal, sometimes purulent and occasionally blood-tinged, vaginal discharge for which patients customarily first seek relief from their gynecologists. Despite this fact, the topic is not mentioned in a single American textbook of gynecology. It is the purpose of this report to review the pertinent literature and to include the authors' experience with 13 additional cases in order to bring this topic to the attention of our gynecologic colleagues.

Combined percutaneous antegrade and cystoscopic retrograde approach in the treatment of distal ureteric fistulae

PURPOSE

To determine the efficacy of a cystoscopic approach, as definitive treatment of ureteral fistulae, after failure of antegrade ureteral stent insertion.

METHODS

Of 43 ureter fistulae encountered over 4 years, 10 postoperative and/or postradiotherapy fistulae could not be stented via an antegrade approach alone. A cystoscopic approach was used, with the antegrade approach available as back-up, if necessary.

RESULTS

In two patients the ureteral orifice could not be visualized cystoscopically, thus precluding the retrograde approach. In the eight remaining patients, the retrograde approach alone never allowed successful stenting. In six patients, combined antegrade and retrograde approaches permitted stent insertions. In three of those six patients, a complex catheterization procedure was necessary. In two patients the combined approach failed altogether. Therefore, 6 of 10 patients underwent a successful stenting procedure with the combined approach; all ultimately closed the fistula.

CONCLUSION

Antegrade stent insertion remains the treatment of choice for ureteral leaks. If the antegrade approach fails, the retrograde approach alone is not likely to be successful. Instead, a combination of both approaches often does succeed.

Ureteric injuries during gynaecological surgery

Thirty-two patients with 35 ureteric injuries encountered during gynaecological surgery are presented. Their mean age was 41 years. Eight ureteric injuries were recognized during surgery, the nature and sites of injury were diagnosed peroperatively using an illuminated size 5 F ureteric probe (Storz) passed through a cystoscope. Three ureteric injuries were diagnosed during convalescence as continuous drainage of urine or urinoma collection, while three patients developed total anuria due to ligation of both ureters. Eighteen patients presented with late urinary fistulae, being uretero-uterine in 8 and ureterovaginal in 10. The ureteric injury occurred during emergency Caesarean section in 15 patients, the indication for Caesarean section being obstructed prolonged labour in 70% of them. Twelve urinary fistulae followed hysterectomy. Intravenous urography, antegrade and retrograde ureterography were useful methods of locating the sites of the fistulae. Ureteroneocystostomy was performed in 18 patients, utilizing a Boari flap in 3 and a bladder psoas hitch in 2. Other methods of treatment are discussed. The mean follow-up was 3 years.

Pouch-vaginal fistula

Between January 1976 and June 1991, 161 women underwent restorative proctocolectomy. Seventeen (10.6 per cent) developed pouch-vaginal fistula. There was no difference in the incidence of inflammatory (15 of 141; 10.6 per cent) and non-inflammatory (two of 20; 10 per cent) disease, the severity of colitis or the number of stages in the operation. In 15 patients the fistula involved the ileoanal anastomosis; in two it had possibly occurred at the dentate line. There was no significant difference in the proportion of hand-sewn (ten of 120; 8.3 per cent) and stapled (seven of 41; 17 per cent) ileoanal anastomosis. Of the 17 women, six had pelvic sepsis in the immediate postoperative period and five had an anastomotic complication. There was no case of Crohn's disease. Three patients developed a pouch-vaginal fistula before closure of the ileostomy. The remaining 14 fistulas occurred a median of 7 (range 1-144) months after closure. Five further patients were referred from elsewhere to give a total of 22 for analysis of treatment and outcome. The fistula developed before ileostomy closure in five patients (group 1) and after closure in 17 (group 2). Following treatment, six fistulas had healed with five patients still undergoing treatment. In group 1, three of the five fistulas healed, whereas in group 2 only three of the 17 healed. Eight patients required excision of the pouch. The prognosis appears to be worse when pouch-vaginal fistula occurs after ileostomy closure. The optimal management is not yet established.

[Conservative treatment of ureteral iatrogenesis of gynecologic origin]

Five patients with iatrogenic ureteral injuries are described herein. Two patients had a vesicoureteric fistula and the remaining three patients had obstructive uropathy secondary to ligation with resorbable material during hysterectomy for a benign uterine condition, which spontaneously resolved with conservative management. Classically, the approach of this type of lesion was interventional and careful patient selection afforded the possibility of definitive resolution. US, CT and modern endourological technology have facilitated temporary diversion via percutaneous nephrostomy (or surgery, if the foregoing is not possible) to protect renal function during the process of recanalization of the injured ureter. Furthermore, it permits radiological control of the course and functional assessment of the excretory tract.

Ureteroscopy: a new asset in the management of postoperative ureterovaginal fistulas

Iatrogenic ureteral injury, an uncommon entity, is primarily caused by complications of gynecologic surgery. This report describes a case of ureterovaginal fistula discovered 13 days after a vaginal hysterectomy. Ureteroscopy was performed, with passage of an indwelling ureteral stent for 6 weeks. The patient immediately became continent of urine and the fistula healed, thus avoiding the need for further surgery.

Treatment of small intestinal fistulas with octreotide, a somatostatin analog

Three patients with external small bowel fistulas were successfully treated with bowel rest, total parenteral nutrition, and the somatostatin analog, octreotide. Two of the patients had received prior multimodality therapy, including radiation, for gynecologic cancer. The time intervals to fistula closure were 2 days, 10 days, and 5 weeks after initiation of octreotide therapy. The efficacy of octreotide combined with total parenteral nutrition in the treatment of external enteric fistulas supports its routine use, especially in previously irradiated patients.

Vaginal fistulas in Crohn's disease

Twenty-eight patients with vaginal fistulas complicating Crohn's disease, seen between 1970 and 1987, are described. Twelve required early operation; five of them had rectal excision. Conservative management was used in 16 patients but in none of these did the fistula close spontaneously. Subsequent proctocolectomy was required in seven patients though two patients with high vaginal fistulas were managed by total colectomy, end ileostomy, and oversewing of the rectal stump. Only two high fistulas resulting from ileal Crohn's disease resolved with resection and anastomosis of the diseased segment alone. Local repair was unsuccessful despite repeated operations in two of five patients. Two patients died of malignancy arising within a chronic vaginal fistula. Although some vaginal fistulas complicating Crohn's disease cause little disability and can be managed symptomatically, they do not heal by conservative therapy or by a proximal defunctioning stoma alone. In time, severe bowel symptoms develop in the majority of patients and necessitate proctectomy.

Perineal sinus after removal of the rectum. Occlusion with fibrin adhesive

Ten patients with a discharging perineal sinus that developed after proctectomy were treated with a new fibrin adhesive system in order to close the sinus. Four of the patients also had a fistula that extended from the sinus to the vagina. Treatment was unsuccessful in two patients: one had retained foreign bodies in the sinus and the other had a rather large spheric cavity. In eight patients the sinus healed after application of fibrin adhesive, even when a fistula to the vagina was present. The method seems to be effective for closing a long, narrow perineal sinus.

Diagnosis and management of ureteral fistulas by percutaneous nephrostomy and antegrade stent catheter

Percutaneous nephrostomy coupled with an antegrade stent catheter was evaluated in 15 patients with uretero-enteric, uretero-cutaneous, uretero-vaginal, or uretero-retroperitoneal fistulas (urinomas). This technique offers an excellent conservative alternative to surgical management or retrograde catheterization.