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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1499_Библиотеки_им_академика_М_И_Перельмана.pdf
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Colovesical fistula on CT scan.
ADDITIONAL TESTS (OPTIONAL)
Imaging studies: cystogram, vaginogram (colpogram).
Small bowel study: small bowel follow-through, CT enterography, capsule endoscopy.
Classification
Colovaginal/-vesical.
High rectovaginal/-vesical.
Enterovaginal/vesical.
Nonoperative Treatment
Bulking of stool.
Operative Treatment
INDICATION
Any symptomatic colovaginal/-vesical fistula.
OPERATIVE APPROACH
Benign disease: resection with primary anastomosis of the intestines, most commonly without major surgery on
bladder/vagina side (possibly simple oversewing).
Malignant disease: en-bloc resection with appropriate reconstruction.
Acute symptoms, hostile pelvis: proximal fecal diversion to gain time later appropriate repair.
Inability to reconstruct: palliative measure fecal (and urinary) diversion only, no plan for repair.
Outcome
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Depending on underlying etiology: benign nature complete recovery, malignant tumor-related prognosis.
Follow-Up
Colovesical fistula: Foley catheter for 10 days, possible cystogram prior to removal.
Benign cause: clinical follow-up after 2–4 weeks, once fistula problem resolved, no specific follow-up needed; routine cancer
screening (per guidelines).
Malignant cause: oncologic treatment and follow-up.
Cross-Reference
Pain, abdominal (Ch. 1)
Sepsis (Ch. 1)
Vaginal air and/or stool passage (Ch. 1)
Conventional x-rays (plain films) (Ch. 2)
Contrast enemas (Ch. 2)
Computed tomography (CT scan) (Ch. 2)
Colorectal cancer—colon cancer (153.X) (Ch. 4)
IBD—Crohn disease (555.X) (Ch. 4)
Large bowel obstruction (LBO, 560.9) (Ch. 4)
Sigmoid resection (open, anastomosis vs Hartmann) (Ch. 5)
Creation of loop ileostomy or colostomy (laparoscopic/open) (Ch. 5)
Laparoscopic colorectal surgery (Ch. 5)
Medications against bacterial and fungal pathogens (App. 1)
RECTOURINARY FISTULA (596.1)
Overview
Rectourinary fistula is a direct communication of the rectum or anal canal with the bladder or urethra. This is a problem of
male patients (in women, vagina/uterus are interposed).
Common causes: congenital anomaly (anorectal malformations); acquired—postsurgical (iatrogenic: prostatectomy, low
anterior resection, etc), pelvic malignancy, radiation injury, inflammatory bowel disease, trauma (perineal, rectal, urethral).
The communication may result in bidirectional flow of feces/bacteria into the urine or leakage of urine through the rectum.
Treatment (type of repair, timing) depends on the severity of symptoms, underlying etiology, tissue quality (eg, after recent
surgery, postradiation, etc), and level of the fistula (in reach from perineum or not?): need to distinguish rectourinary fistula
(low) from colovesical or enterovesical fistula (high).
Epidemiology
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Rare, but significant number in tertiary referral centers. Overall incidence unknown because of various different etiologies.
Symptoms
Symptomatic: pneumaturia, fecaluria, urinary tract infection/sepsis, hematuria, rectal bleeding and leakage of urine, pelvic
pain.
Asymptomatic.
Differential Diagnosis
Colovesical fistula (see separate discussion earlier).
Rectourinary fistula:
Local abscess (perirectal abscess, etc).
Posttraumatic: Foley catheter insertion, foreign body, etc.
Postsurgical: prostatectomy, hemorrhoidectomy, LAR, IPAA, etc.
Malignancy.
Crohn disease.
Radiation-induced (particularly brachytherapy, eg, prostatic seeds, etc).
Lymphogranuloma venereum.
Congenital rectourinary fistulae (eg, in conjunction with imperforate anus).
Pathology
Depending on underlying etiology.
Evaluation
REQUIRED MINIMAL STANDARD
History: exact description and sequence of symptoms? Previous diseases, previous surgeries, timing, previous radiation
therapy educated guess: abdominal or pelvic origin? Previously attempted repair? Comorbidities?
Clinical examination: rectal exam, anoscopy/rigid sigmoidoscopy
visible opening? Cystoscopy identification and location
of defect? Abdominal exam distinction between low- or mid-level rectourinary fistula (trigonum or below) from high
rectourinary/colovesical fistula (bladder dome).
Setting priority for further tests.
ADDITIONAL TESTS (OPTIONAL)
Imaging studies: cystogram/urethrogram, contrast enema (Figure 4–20), CT/MRI.
Figure 4–20.
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Rectourinary fistula.
Endoscopy (colonoscopy, flexible sigmoidoscopy): (1) for evaluation, (2) for screening purposes according to guidelines.
Classification
High: colovesical, enterovesical, high rectovesical fistula.
Mid-level: rectourinary fistula.
Low: rectourinary fistula, anourinary fistula.
Nonoperative Treatment
No/minimal symptoms conservative management: bulking of stool, antibiotics, Foley or suprapubic catheter, possibly
percutaneous nephrostomy tubes.
If patient already diverted
waiting 3–6 months and reassessment.
Operative Treatment
INDICATION
Any symptomatic rectourinary fistula.
OPERATIVE APPROACH
Temporizing approach: proximal fecal diversion to gain time (eg, highly symptomatic, shortly after previous surgery)
appropriate repair electively 3–6 months later.
Primary/secondary repair (depending on etiology, timing): perineal vs transabdominal approach:
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Transanal/transrectal approach (through York-Mason approach) layered closure and rectal advancement flap.
Transperineal approach with tissue interposition: eg, gracilis muscle, Dartos flap, urethral grafting (eg, buccal
mucosal graft).
Transabdominal approach:
– LAR/coloanal, omentum interposition.
– Cystectomy/urinary conduit, abdominal repair of rectal defect.
Definite palliative measure with no plan for repair/reconstruction: fecal diversion, APR/pelvic exenteration.
Outcome
Dependent on underlying etiology, tissue quality, number of previous attempts, nutrition, type of reconstruction.
Follow-Up
Recheck patient after 2–4 weeks of initiated or performed treatment. Once fistula problem resolved planning of ostomy
takedown; otherwise no fistula-specific, but potentially disease-specific follow-up needed.
Cross-Reference
Pain, abdominal (Ch. 1)
Sepsis (Ch. 1)
Conventional x-rays (plain films) (Ch. 2)
Contrast enemas (Ch. 2)
Computed tomography (CT scan) (Ch. 2)
IBD—Crohn disease (555.X) (Ch. 4)
Diverticular disease (diverticulosis, diverticulitis, 562.1X) (Ch. 4)
Colovaginal and colovesical fistula (619.1, 596.1) (Ch. 4)
Complications—leak (997.4) (Ch. 4)
York-Mason approach (Ch. 5)
RECTOVAGINAL FISTULA (619.1)
Overview
Rectovaginal fistula is a direct communication of the rectum or anal canal with the vagina. Following a high-to-low pressure
gradient, both stool and gas may pass through the vagina. The amount of material passing depends on the diameter and
length of the fistula track, its exact location, the stool consistency, and the absolute endorectal pressure build-up.
Most rectovaginal fistulae are acquired, eg, postobstetric injury or anorectal surgery (rectocele repair, hemorrhoidectomy,
LAR), radiation injury, perirectal/-neal abscesses (cryptoglandular, Crohn disease).
Treatment (type of repair, timing) depends on the severity of symptoms, underlying etiology, tissue quality (eg, after recent
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surgery, postradiation, etc), and level of the fistula (in reach from perineum or not?): need to distinguish rectovaginal fistula
from colovaginal or enterovaginal fistula (high).
Epidemiology
Incidence: overall unknown because of various different etiologies. Obstetric injuries in 0.1–1% associated with rectovaginal
fistula, radiation in 1–6%, Crohn disease in 5–10%.
Symptoms
Passage of gas or stool through vagina.
Associated symptoms: pain, bleeding, altered bowel habits, diarrhea, fever/sepsis, urinary tract infections, perianal/-vulvar
skin irritation.
Very small fistulae may be asymptomatic.
Differential Diagnosis
Colovaginal fistula (see separate discussion in this chapter).
Rectovaginal fistula:
Local abscess (perirectal abscess, Bartholin abscess, etc).
Posttraumatic: obstetric injury, foreign body, etc.
Postsurgical: hemorrhoidectomy, rectocele repair, LAR, IPAA, etc.
Malignancy.
Crohn disease.
Radiation-induced (particularly brachytherapy, eg, cervical cap, etc).
Lymphogranuloma venereum.
Congenital rectovaginal fistulae (eg, in conjunction with imperforate anus).
Pathology
Dependent on underlying etiology.
Evaluation
REQUIRED MINIMAL STANDARD
History: exact description and sequence of symptoms? Previous diseases, previous surgeries, timing educated guess:
abdominal or pelvic origin? Previously attempted repair?
Clinical examination: rectovaginal exam, anoscopy/rigid sigmoidoscopy, abdominal exam
distinction between low- or mid-
level rectovaginal fistula from high rectovaginal or colovaginal fistula.
Setting priority for further tests.
ADDITIONAL TESTS (OPTIONAL)
Air bubbling test: colposcopy (in Trendelenburg position, saline in vagina), rectal air insufflation via rigid sigmoidoscope air
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bubbling on vaginal side?
Tampon test: insertion of vaginal tampon, rectal instillation of
1
/
2
ampulla of methylene blue in ~200 mL saline, check
tampon 30 minutes later positive if blue at tip of tampon, but base clear), vs false positive (distal overflow), negative,
false negative.
Imaging studies: contrast enema, vaginogram (colpogram), CT/MRI.
Endoscopy (colonoscopy, flexible sigmoidoscopy): (1) for evaluation, (2) for screening purposes according to guidelines.
Classification
High: colovaginal, enterovaginal, high rectovaginal fistula.
Mid-level: rectovaginal fistula.
Low: rectovaginal fistula, anovaginal fistula.
Nonoperative Treatment
Bulking of stool.
If patient already diverted
wait 3–6 months and reassess.
Operative Treatment
INDICATION
Any symptomatic rectovaginal fistula.
OPERATIVE APPROACH
Temporizing approach: proximal fecal diversion to gain time (eg, highly symptomatic, shortly after previous surgery)
appropriate repair electively 3–6 months later.
Definite palliative measure with no plan for repair/reconstruction: fecal diversion, APR.
Primary/secondary repair (depending on etiology, timing): perineal vs transabdominal approach:
Endorectal advancement flap.
Transfistular rectoperineovaginotomy with layered reconstruction of rectovaginal septum/perineum.
Insertion of collagen plug.
Seton management.
Transperineal interposition: eg, collagen, muscle—gracilis muscle, rectus abdominis, bulbocavernosus muscle (=
Martius flap).
Transabdominal approach: LAR/coloanal anastomosis, omentum interposition.
Not indicated: fistulotomy, vaginal flap.
Outcome
Dependent on underlying etiology, tissue quality, number of previous attempts, nutrition, type of reconstruction.
Follow-Up
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Recheck patient after 2–4 weeks of initiated or performed treatment. Once fistula problem resolved planning of ostomy
takedown; otherwise no fistula-specific, but potentially disease-specific follow-up is needed.
Cross-Reference
Sepsis (Ch. 1)
Vaginal air and/or stool passage (Ch. 1)
Contrast enemas (Ch. 2)
Computed tomography (CT scan) (Ch. 2)
Colovaginal and colovesical fistula (619.1, 596.1) (Ch. 4)
Rectovaginal fistula repair—advancement flap (Ch. 5)
Creation of loop ileostomy or colostomy (laparoscopic/open) (Ch. 5)
ENDOMETRIOSIS (617.X)
Overview
Endometriosis is the presence of functional endometrium outside the uterus. As pathogenesis remains unclear, different
theories have evolved: endometriosis foci stemming from retrograde menstruation vs celomic metaplasia vs direct
dissemination during GYN surgery.
Epidemiology
Typical age: 20–40 years. Endometriosis involving intestines in 10–30%, majority of which show at least some symptoms.
Symptoms
Depending on the location:
GYN symptoms: infertility, dysmenorrhea, dyspareunia, etc.
Bowel symptoms: cyclic bleeding, obstruction with constipation/diarrhea, cyclic pain/tenesmus; if near surface
(perineum, rectovaginal septum)
cyclic swelling and pain; perforation rare.
Bladder symptoms: bleeding, dysuria, urgency.
Incidental finding of pelvic mass (CT scan, MRI, ultrasound).
Differential Diagnosis
Bowel symptoms or mass related to other causes: cancer, diverticulitis, Crohn disease, etc.
Pathology
Functional endometrium (no neoplastic activity) in ectopic sites, either extrinsic or involving mucosa, desmoplastic reaction,
formation of adhesions. Locations: cul-de-sac, sigmoid colon, ovary, appendix, small bowel, other colon.
Evaluation
REQUIRED MINIMAL STANDARD
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History: careful evaluation of symptoms and relationship to menstrual cycle clinical suspicion. Further hint from
responsiveness to hormonal therapy (eg, gonadotropin-releasing hormone agonists, danazol, etc).
Clinical examination (ideally around menstrual bleeding), including bidigital exam of rectovaginal septum (
visible/palpable
lesions?)
Rigid/flexible sigmoidoscopy: extrinsic fixation and angulation, tethering of mucosa.
Full colonic evaluation: colonoscopy vs contrast enema, biopsies rarely conclusive if mucosa not involved (but rules out
colorectal cancer).
GYN evaluation.
ADDITIONAL TESTS (OPTIONAL)
CT/MRI abdomen/pelvis.
Endorectal/transvaginal ultrasound.
Classification
Based on:
Number and distribution pattern of endometriosis implants.
Depth of implants penetration: deeply penetrating vs superficial.
Severity of perifocal scar tissue (adhesions).
Nonoperative Treatment
Asymptomatic or little symptomatic intestinal endometriosis: oral contraceptives, danazol, gonadotropin-releasing hormone
agonists (eg, leuprolide, goserelin, etc).
Operative Treatment
INDICATIONS
Symptomatic treatment-refractory endometriosis.
Intestinal endometriosis: obstruction, or if diagnosis in doubt (eg, pelvic mass).
Incidental finding during surgery for other cause.
OPERATIVE APPROACH
Laparoscopic/open removal of endometriosis foci, complete whenever possible.
Segmental bowel resection vs focal bowel wall excision.
Preservation of fertility no oophorectomy/hysterectomy without consent!
Outcome
Postoperatively, symptomatic pain relief > 80%, nearly complete relief of cyclic bleeding and obstructive symptoms,
satisfaction in 50–80% of patients (depending on whether oophorectomy performed or not).
Follow-Up
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Functional reevaluation at regular intervals. Role for postoperative prophylactic medical management not corroborated.
Cross-Reference
Bleeding per rectum (Ch. 1)
Large bowel obstruction (LBO) (Ch. 1), (Ch. 4)
Pain, abdominal (Ch. 1)
Pain, perirectal (Ch. 1)
Computed tomography (CT scan) (Ch. 2)
Colorectal cancer—colon cancer (153.X) (Ch. 4)
IBD—Crohn disease (555.X) (Ch. 4)
Sigmoid resection (open, anastomosis vs Hartmann) (Ch. 5)
Laparoscopic colorectal surgery (Ch. 5)
ACUTE LOWER GI BLEEDING (578.9)
Overview
Acute lower GI bleeding may be brisk and life-threatening unless decisive management prevents a patient's fatal
deterioration. Immediate resuscitation and transfusions are key to maintaining hemodynamic stability. Active intervention is
desirable but requires identification of a target. However, there is no universally applicable sequence of investigations, and
positive identification of the bleeding source often remains elusive for several reasons:
Bleeding is a common symptom of a wide spectrum of different causes and locations.
Bleeding may originate from any segment of the GI tract and unselectively accumulate in others.
Severity may vary with time: severe bleeding may often occur intermittently with often long and equally
unpredictable interval periods in between.
Emergency surgery with educated guess of likely bleeding source may be the only option but carries associated morbidity
and mortality and may not prevent recurrent bleeding.
Epidemiology
Incidence: unknown, 0.5–1% of hospital admissions; 75–85% of bleeding episodes spontaneously stop. Recurrent bleeding
in 25–40% (depending on etiology).
Symptoms
Bleeding per rectum: bright red, dark red, melena—rectal evacuation potentially significantly delayed to actual bleeding
episode.
Depending on magnitude of bleeding: associated hemodynamic impact.
Differential Diagnosis
Colonic Origin