Recurrent fistula

Percutaneous drainage may be limited by antelocated intestinal loops or by abscesses that are difficult to reach. Similarly, surgery is indicated following unsuccessful percutaneous drainage, in extensive cavernous or multifocal abscesses, tissue sequestration, formation of enteral fistula and viscous abscess contents as well as local recurrences. With abscess perforation or the existence of other purulent foci in the abdomen, surgical intervention is called for immediately. 

Infliximab (5 mg/kg infused intravenously at intervals of several weeks to months) decreases the frequency of acute flares in approximately two thirds of patients with moderate to severe Crohn s disease and also facilitates the closing of enterocutaneous fistulas associated with Crohn s disease. Its longer-term role in Crohn s disease is evolving, but emerging evidence supports its efficacy in maintaining remission and in recurrence of hstulas. 

Antibiotics can be used as either (1) adjunctive treatment along with other medications for active IBD (2) treatment for a specific complication of Crohn s disease or (3) prophylaxis for recurrence in postoperative Crohn s disease. Metronidazole, ciprofloxacin, and clarithromycin are the antibiotics used most frequently. They are more beneficial in Crohn s disease involving the colon than in disease restricted to the Ueum. Specific Crohn s disease-related complications that may benefit from antibiotic therapy include intra-abdominal abscess and inflammatory masses, perianal disease (including fistulas and perirectal abscesses), small bowel bacterial overgrowth secondary to partial small bowel obstruction, secondary infections with organisms such as Clostridium difficile, and postoperative complications. Metronidazole may be particularly effective for the treatment of perianal disease. Postoperatively, a 3-month course of metronidazole (20 mg/kg/day) can prolong the time to both endoscopic and clinical recurrence. 

Abdominal ultrasound (US), thanks to its accuracy, good repeatability and non-invasiveness is currently employed in many chronic inflammatory conditions, not only for purely diagnostic purposes, but also for management of the disease. In Crohn s disease (CD) patients, US has become the first-line imaging procedure for early diagnosis of the disease (Parente et al. 2004a), and more frequently for the follow-up, to detect intra-abdominal complications (strictures, fistulae and abscesses), to assess activity and monitor the course of disease, as a prognostic index of recurrence (Table 7.1). 

Maconi G, Sampietro GM, Cristaldi M et al (2001) Preoperative characteristics and postoperative behaviour of bowel wall on risk of recurrence after conservative surgery in Crohn s disease. A prospective study. Ann Surg 233 345-352 Maconi G, Sampietro GM, Russo A et al (2002) The vascularity of internal fistulae in Crohn s disease an in vivo power Doppler ultrasonography assessment. Gut 50 496-500... 

Recurrent esophagorespiratory fistula and a dilated esophagus above a previously placed stent. 

Covered metallic stents provide effective treatment for malignant flstulas and perforations. The clinical success rates are very high and most patients derive relief from symptoms of aspiration or debilitating thoracic sepsis. Patients with recurrent flstulas or leaks may be treated by additional overlapping stents in most cases. Metallic stents placed in the airways may be useful for some patients with a dilated esophagus, very high fistulas, or airway obstruction due to local invasion by esophageal tumors. 

During the follow-up of patients with high-llow priapism, we recommend color Doppler ultrasound 1-2 months after embolization to confirm the absence of recurrent fistula. Recanalization of the em-bolized cavernosal artery can be observed also when non-reabsorbable embolization material has been used (Savoca et al. 2004). In patients with erectile dysfunction, the study should be performed after in-tracavernosal prostaglandin injection to determine whether the functional impairment is caused by insufficient penile blood flow or not. 

Besides evaluation of penile blood supply to the penis, MDCT can be indicated to evaluate large postoperative fluid collections and complications of urethral surgery such as diverticula, fistulas and postoperative strictures (Chou et al. 2005). Also prosthesis malfunction can be investigated in patients who are not candidates for magnetic resonance imaging. Moreover, in patients with penile and urethral malignancies, CT is often used after the operation to evaluate the pelvis in suspicious postoperative complications extending into the perineum and into the pelvis, such as fistulas and inflammation. Also tumor recurrence and pelvic lymphadenopathies can be evaluated effectively. 

Sfakianos GP, Numnum TM, Halverson CB, Panjeti D, Kendrick IV JE, Straughn Jr. JM. The risk of gastrointestinal perforation and/or fistula in patients with recurrent ovarian cancer receiving bevacizumab compared to standard chemotherapy a retrospective cohort study. Gynecol Oncol 2009 114 (3) 424-6. 

Technical success of embolization for intrarenal vascular injury is quite high, around 95-100% [42-44]. Typically the recurrence rate is nearly 0% however, in one series a second embolization session was needed in 2 (15%) of 13 patients to fully occlude arteriovenous fistulas and achieve true technical success [44]. An analysis of the effect on renal function of selective embolization for traumatic renal lesions revealed that the mean volume of infarcted kidney was only 6% (range 0-15%) and 1 week postembolization the serum creatinine was normal in all their patients [42]. A series of renal transplants estimated that the maximal volume of infarcted kidney after embolization for biopsy-related injuries was always less than 30% [44]. Also, while renal function dete-... 

The second category of rCBS was best defined simply as events attributable to treatment failures (TF) (i.e. rCBS attributable to same affected arterial segment or territory that had been previously treated). This included recurrent bleeding from a previously treated arterial pseudoaneurysm, arterial fistula, or tumor neovasculature. Interestingly, the time course between recurrent events attributable to TF tended to be relatively short, varying between 1 and 10 days. In our cumulative series we found that approximately 32% rCBS could be attributable to treatment failures. 

Breakdown of suture lines and leakage are a common complication of the early postoperative phase. Afferent loop syndrome is a specific problem of Billroth II procedures and is caused by mechanical obstruction usually from adhesions. Internal hernias, extrinsic compression, bowel stenosis may also occur. Bezoar formation in the gastric remnant, anastomotic ulcers, incisional hernia of the abdominal wall and hiatal hernia are all also potential complications. Stenosis of the gastrojejunostomy after Billroth II procedures leads to obstruction (Fig. 13.14). Fistula after Billroth II is rare (Fig. 13.15). Tumour of the gastric renmant can be due to recurrence or present as a primary carcinoma of the stump (Fig. 13.16). 

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