Colovesical fistula - Forum

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Chirurgia

Re: Colovesical fistula - Ärzteforum

Post#11 »

I never said that an anastomosis shouldn't be performed in ALL Crohn patients. Although may be I'm "younger" and less skilled than you, I didn't send that case just "pour parler" nor pretending to state any absolute guideline...the sense was just this: an anastomosis in a Crohn patient on full corticosteroid and /or cyclosporine treatment is not so safe. That's all.


Poland

Re: Colovesical fistula - Ärzteforum

Post#12 »

I vote for a Hartman of course.

सर्जन

Re: Colovesical fistula - Ärzteforum

Post#13 »

In general I agree that stomas are less and less indicated. Thus, I resect and anastomose obstructed large bowel; I respect and anastomose perforated sigmoid diverticulitis. I do it but SELECTIVELY.

I developed "respect" for the patient -on prolonged steroid Rx - for complicated IBD.

I have seen patients (refereed to me) in whom "everything fells apart" after restorative proctocolectomy for IBD- they were on steroids. I won't forget a young Crohn's patient -as usual - on futile steroid Rx for an non-resolving ileo-cecal abscess/phlegmon. I did a R hemicolcectomy and ileo-transvere anastomosis- one layer running PDS. Five days later I had to operate on him - there was no anastomosis! I found the PDS a mile away!

This is level 6 evidence. But I respect the tissues weakened by steroids.

Many factors affect the healing of an anastomosis and I like to consider them all in my decision whether to anastomsoe or not.

Elective bowel resection in a well nourished patient on steroids- no intra-abdominal infection. I would tend to anastomose.

Emergency bowel resection on steroids -poorly nourished patient, IP abscess- I would not anastomose.

Those are the two ends of the spectrum- in between one needs judgment (Consider the: 1. bowel. 2. patient. 3. peritoneal cavity. 4. surgeon) and luck- there are no formulas or scoring system.

I hate stomas as you do. But one thing is sure- a leaking anastomosis has a mortality of close to 50%! Stomas have morbidity but no mortality. Closure of stomas has some mortality -around 1- %.

I prefer a walking patient with a stoma than a dead one without. Still, you are right -in the majority of patients stoma could be avoided.

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Old surgeon

Re: Colovesical fistula - Ärzteforum

Post#14 »

I would agree with your sage comments wholeheartedly with regard to using ostomy selectively--obviously I do ostomies , altho less now than I used to. I am just against a blanket generalization that steroids mandate ostomy--obviously a host of other variables come into play, and in the absence of firm answers, judgement must supervene--which is why 10 different surgeons on this list will come up with 10 different answers. But I would also guess that if these 10 surgeons were present at any given case, we would largely agree on our approach. Also--don't forget the use of Vitamin A perioperatively--a proven adjunct to improve wound healing--on how many of the cases you saw break down was it being used?

Chirurgia

Re: Colovesical fistula - Ärzteforum

Post#15 »

I explored her and found a thickened sigmoid colon with muscular hypertophy but only one non-inflamed diverticulum. The fistula was in an otherwise normal area of bowel with a tunnel through the subcutaneous fat to the bladder. Although I couldn't prep her pre-op I went in hoping to hook her up. I found that her rectum and rectosigmoid were very inflamed to the point where the serosa wouldn't hold suturres. I ended up with a Hartman. She did well and has been discharged. In retrospect her major symptoms began around the time of her biopsy in October. I wonder if she had a small perforation from the biopsy that eventually eroded into the bladder. Thererwas no sign of Crohn's disease as expected.

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