Fistulas and Postoperative Leakages

W. Schmidbaur

The formation of fistulas or anastomotic leakages can be associated with inflammatory diseases (especially Crohn disease) or therapeutic interventions, which lead to disruption in the continuity of the walls of hollow organs (Tab. 22.1).

This chapter addresses relevant aspects of these diseases for the colonoscopist. Enterocutaneous fistulas (like the perianal fistula in Fig. 22.1) will not be specifically discussed as they are often complex proctological or surgical problems that would be beyond the scope of this book.

Colovesical fistulas. Colovesical fistulas occur in up to 2% of patients with diverticulitis (references in 2). Other causes include Crohn disease, malignancy, radiation therapy, and trauma. The rate of spontaneous healing is very low (2%). Thus, surgical intervention is usually the therapy of choice, though endoscopic therapy can also be attempted. Fistulas can also occur involving the urethra (Fig. 22.2).

Table 22.1 Definitions

Fistulas

► Present at birth or acquired tubelike connections between two cavities or one cavity and the skin surface

Anastomotic leakage

► Any extraluminal extravasation from the region around an anastomosis is an anastomotic leak: defined as a complete bowel wall defect in the region around a surgical suture leading to communication between intraluminal and extraluminal spaces (7)

Rectovaginal fistulas. Rectovaginal fistulas (Figs. 22.3-22.5) are also usually due to therapy-related or inflammatory causes. If endoscopic therapy is attempted, it should be performed together with a gynecologist if possible.

Enteroenteric and enterocutaneous fistulas. There is normally no endoscopic therapy approach for enteroenteric and enterocu-taneous fistulas that appear, for example, in Crohn disease (Figs. 22.6,22.7). Therapy mainly consists of medication and, if necessary, surgical intervention.

Perianale Fistel

Perianal fistula opening in Crohn

Fig. 22.3 Rectovaginal fistula. The small opening of this fistula was hidden behind a rectal fold and was thus not visible under endoscopy. It was identified at transvaginal cannulation.

disease.

Perianal fistula opening in Crohn

Fig. 22.2 Radiation-induced fistula including the urethra (prior rectal carcinoma).

disease.

Tiny Vagina

Fig. 22.4 Radiation-induced fistula in vagina (prior rectal carcinoma).

Transvaginal

Fig. 22.5 Fistula not immediately visible during endoscopy. The fistula was found after administration of a contrast dye in the ulcerlike defect.

Fig. 22.3 Rectovaginal fistula. The small opening of this fistula was hidden behind a rectal fold and was thus not visible under endoscopy. It was identified at transvaginal cannulation.

Fig. 22.5 Fistula not immediately visible during endoscopy. The fistula was found after administration of a contrast dye in the ulcerlike defect.

Fistulizing Crohn Disease

Fig. 22.6 Fistulizing Crohn disease.

a Severe initial episode of Crohn disease. Fistulas were first discovered in the duodenum.

b The other end of the fistulous tract with several openings in the colon; widespread inflammation and ulcers next to the tract.

Fistula Openings

Fig. 22.7 Tiny fistula opening in an indentation next to the Bauhin valve. The fistula ended after a few centimeters in the terminal ileum, which had massive inflammatory changes.

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Responses

  • yusuf thompson
    Is a fistula to the sigmoid colon an indication of an anastomosis leak?
    1 year ago
  • Tesfalem Kidane
    Can a second bladder fistula develope after sigmoid colon restructive surgery?
    4 months ago

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