BACKGROUND

Gastric outlet obstruction (GOO) results from intrinsic and extrinsic obstruction of the pyloric channel or the duodenum. Here we present a rare case of GOO attributed to dense adhesions between the gallbladder and duodenum secondary to chronic cholecystitis with choledococystoduodenal fistula formation. Previous reports identified elderly females with comorbidities as a predisposing factor; however, our patient was an immunocompetent adult male.

A 43-year-old male with no comorbidities consulted for recurrent epigastric pain, vomiting and weight loss. On contrast enhanced abdominal CT scan, a lamellated cholelithiasis with pneumobilia and an irregular thickening at the proximal duodenum with subsequent GOO was identified. A choledococystoduodenal fistula was considered. Exploratory laparotomy revealed extensive fibrosis and cholecystitis with dense adhesions to surrounding structures. Dissection revealed a gallstone impacted in and adherent to the wall of the gallbladder and a fistula opening into the duodenum. However, there was no definite evidence of impacted gallstone in the duodenum. The dense adhesions secondary to chronic cholecystitis caused duodenal narrowing and subsequent GOO. He eventually underwent antrectomy, pancreatic sparing, total duodenectomy, cholecystectomy, with loop gastrojejunostomy, cholecystojejunostomy and pancreaticojejunostomy. Biopsy specimens taken were negative for malignancy. He was discharged subsequently. However, he was readmitted after five months due to acute abdomen secondary to small bowel rupture, likely from a marginal ulcer.

This case highlights that preoperative and intraoperative differential diagnosis of GOO is a challenge. Chronic calculous cholecystitis through severe inflammation can present as a rare cause of GOO. Optimal treasaFtment plan should take into consideration the underlying etiology of the GOO.

OBJECTIVE: To observe the effect of Dong's extraordinary point needling technique on postoperative complications of anal fistula. METHODS: A total of 241 patients undergoing anal fistula surgery were randomly divided into an observation group (121 cases, 3 cases dropped off) and a control group (120 cases, 2 cases dropped off). The patients in the control group were treated with intramuscular injection of compound diclofenac sodium injection and oral administration of tamsulosin hydrochloride sustained release capsules. In addition to the treatment in the control group, the patients in the observation group were treated with Daoma needling technique at the "Sanqi points" (Qimen point, Qijiao point, and Qizheng point) combined with Dongqi needling technique at "Sanhuang points" (sub-Tianhuang point, Dihuang point, Renhuang point), with each session lasting 30 min. The treatment in the two groups both started on the first day after surgery, and was given once daily for 14 consecutive days. Visual analog scale (VAS) score was compared between the two groups on postoperative day 1, 7, and 14; bladder residual urine volume, spontaneous voiding volume, and urinary catheterization frequency were assessed after treatment on postoperative day 1; and anorectal dynamic indexes (anal canal resting pressure, rectal resting pressure, maximum squeeze pressure of the anal canal, and minimum rectal sensory threshold) were evaluated before surgery and on postoperative day 4. Clinical efficacy was assessed in both groups one month after surgery. RESULTS: On postoperative day 7 and 14, the VAS scores of both groups were lower than those on postoperative day 1 (P<0.05), and the VAS scores in the observation group were lower than those in the control group (P<0.05). The bladder residual urine volume and urinary catheterization frequency in the observation group were lower than those in the control group (P<0.05), while the spontaneous voiding volume was higher than that in the control group (P<0.05). On postoperative day 4, the anal canal resting pressure, maximum squeeze pressure of the anal canal, and the minimum rectal sensory threshold were lower than preoperative values (P<0.05), while the rectal resting pressure was higher than preoperative value (P<0.05) in both groups. The anal canal resting pressure, maximum squeeze pressure of the anal canal, and minimum rectal sensory threshold were lower than those in the control group, and the rectal resting pressure was higher than that in the control group (P<0.05). The effective rate was 93.2% (110/118) in the observation group, which was higher than 84.7% (100/118) in the control group (P<0.05). CONCLUSION Dong's extraordinary point needling technique could reduce postoperative pain, alleviate urinary retention, and improve defecation in patients undergoing anal fistula surgery.
Humans ; Rectum ; Rectal Fistula/surgery* ; Anal Canal/surgery* ; Treatment Outcome ; Anus Diseases ; Postoperative Complications/etiology* ; Acupuncture Points

Open abdomen therapy is an effective treatment to deal with severe abdominal infections, abdominal hypertension and other critical abdominal diseases. However, this therapy is difficult to implement and has many uncertainties in the timing, manners, and follow-up treatment, which leads to the fact that open abdomen therapy is not very accessible and standardized in medical systems of China. This consensus aims to provide guiding principles for indications and implementation of open abdomen, classification methods of open abdomen wounds, technologies for abdominal closure, and management of enteroatmospheric fistula, so as to improve the accessibility and success rate of open abdomen in China.
Humans ; Abdomen/surgery* ; Consensus ; Intestinal Fistula/therapy* ; Negative-Pressure Wound Therapy ; Open Abdomen Techniques

Rectovaginal fistula (RVF) is an abnormal connection between the rectum and the vagina. At present, the principle method for RVF is surgery. With a variety of surgical methods, clinicians still lack a generally recognized consensus on RVF. Therefore, based on latest evidence from literature and expert experience, the Clinical Guidelines Committee of Chinese Medical Doctor Association Anorectal Branch organized domestic experts in anorectal surgery and gynecology to discuss the etiology, classification, diagnosis, treatment and special types of rectovaginal fistula of RVF, through questionnaires and expert seminars. "Chinese experts consensus on the diagnosis and treatment of rectovaginal fistula (2022 edition)" was produced in order to deepen the understanding of RVF, and to provide a standardized treatment for RVF in order to reduce the failure rate of surgery.
Female ; Humans ; Rectovaginal Fistula/surgery* ; Consensus ; East Asian People ; Rectum/surgery* ; Vagina/surgery*

Objective: To explore the possibility that the intestinal flora profile in complex anal fistula patients is different to that of healthy controls. This was assessed by sequencing of 16S rDNA in fecal samples from cohorts representing these populations. Methods: Fecal samples were collected from 30 complex anal fistula patients and 30 matched healthy controls. Patients were included if they met the diagnostic criteria of cryptoglandular anal fistula and had exhibited symptoms for more than 3 months. Complex anal fistula is diagnosed under the following circumstances: if the fistula in question spans 2/3 or more of the diameter of the anal sphincter; if there are more than two external orifices or fistula tracks; or if recurrence is observed after previous anal fistula surgery. Patients were excluded if there were comorbities including inflammatory bowel disease (as assessed by colonoscopy), chronic diarrhea, chronic constipation, diabetes, gastrointestinal malignancies, liver/ kidney dysfunction, or cognitive impairment. Patients whose anal fistulas were caused by Crohn's disease, trauma, special infections (such as actinomycosis and tuberculosis) were also excluded, as were those who had used antibiotics, prebiotics, or probiotics that may affect intestinal microecology in the month prior to the study. Total bacterial genomic DNA was extracted by PCR amplification of the V4 hypervariable region of the 16S rRNA sequences. High-throughput sequencing and data analysis were performed on the Illumina Miseq platform. Finally, operational taxonomic unit (OTU) clustering, alpha diversity and LEfSE data analysis were carried out. The larger the Chao or ACE index is, the higher the species abundance of the microflora is expected to be. Similarly, a smaller value for the Simpson index or a larger value for the Shannon index indicates greater microflora diversity. There was no statistically significant difference in gender, age, body mass index (BMI), drinking history, or smoking history between the two groups (P>0.05), indicating that they were comparable. Results: The α-diversity analysis including ACE, Chao, Shannon and Simpson indexes indicated a richer diversity of intestinal microflora in complex anal fistula patients than in healthy controls. In both patients and controls, OUT cluster analysis demonstrated that 93.4%±32.0% and 87.4%±41.2% of sequences were from Firmicutes and Bacteroidetes spp., respectively. On a genus level, samples from anal fistula patients showed a greater abundance of Prevotella spp. (4.9%±7.4% vs. 0.1%±1.1%, P<0.001), Megamonas (3.9%±8.2% vs. 0.5%±4.2%, P<0.05) and Lachnospira (2.6%±5.7% vs. 0.1%±3.4%, P<0.05), while showing a lesser abundance of Proteobacteria spp. (0.02%±4.2% vs. 9.3%±14.4%, P<0.01), Enterococcus (0.02%±2.3% vs. 9.3%±19.6%, P<0.05), Bacteroides (24.7%±9.9% vs. 29.8%±9.1%, P<0.05) and Klebsiella (0.4%±4.2% vs. 3.9%±7.3%, P<0.05) compared with healthy controls. Intestinal flora diversity in the complex anal fistula group was richer than in controls, as indicated by a higher ACE index (293.30±44.00 vs. 218.75±33.83, t=102.069, P<0.001), a higher Chao index (318.40±41.99 vs. 250.00±46.38, t=77.818, P=0.028), a higher Shannon index (3.36±0.29 vs. 2.43±0.34, t=9.657, P=0.001), and a lower Simpson index (0.103±0.013 vs. 0.131±0.013, t=5.551, P=0.046). LDA effect size analysis suggests that the main strains of Veillonellaceae, Selenemondales and Negativicutes, which all belong to the phylum Firmicutes, have the greatest influence on the above difference (LDA>4). Conclusions: The diversity of intestinal flora in patients with complex anal fistula is greater than in healthy controls, suggesting that these bacteria or their metabolites may be involved in the occurrence and development of anal fistulas.
Anti-Bacterial Agents ; Bacteria/genetics* ; DNA, Ribosomal ; Gastrointestinal Microbiome ; Humans ; RNA, Ribosomal, 16S/genetics* ; Rectal Fistula/surgery*

OBJECTIVE: To evaluate the clinical therapeutic effect of electroacupuncture (EA) at METHODS: The data of 318 patients undergoing anal fistula surgery were analyzed retrospectively. In accordance with whether accepted the combined treatment with EA at bilateral RESULTS: For VAS score, there was an interaction between therapeutic method and treatment duration ( CONCLUSION Electroacupuncture at
Acupuncture Points ; Acupuncture, Ear ; Electroacupuncture ; Humans ; Rectal Fistula/therapy* ; Retrospective Studies

Cannula ; Catheters ; Drainage ; Duodenal Diseases ; Humans ; Intestinal Fistula/surgery*

: Objective: To investigate the efficacy of fistula stent made by 3D printing technique in the treatment of enteroatmospheric fistula. Methods: A descriptive case series study was carried out. INCLUSION CRITERIA: (1) patients with open abdomen; (2) patients with enteroatmospheric fistula. EXCLUSION CRITERIA: (1) patient with two or more fistulas; (2) distal obstruction; (3) bowel stenosis over 50%. According to above criteria, 17 EAF patients admitted to the General Surgery Department of Jinling Hospital from June 2019 to January 2020 were retrospectively included in study. Based on the intestinal radiography, CT reconstruction and finger exploration, the size of fistula, the diameter of the intestinal tube and the angle of the intestinal lumen around the fistula were assessed. The 3D printing fistula stent was designed and established based on estimated data, and then placed through the fistula. OUTCOME MEASUREMENTS (1) success rate of stent implantation; (2) outflow of intestinal contents after implantation; (3) tolerated exercise time; (4) receiving definite operation time for intestinal fistula; (5) time to recovery of enteral nutrition. The t-test was used to compare the outflow amount of intestinal content before and after the stent implantation and the tolerated exercise time. The changes of the outflow amount of intestinal content and tolerated exercise time were analyzed by repeated measurement ANOVA. Results: Seventeen EAF patients with open abdomen included 13 males and 4 females. All the patients successfully received intestinal fistula stent implantation. Gastrointestinal angiography 2 days after implantation showed that the digestive tract was unobstructed, and the stent was successfully kept in place until definite surgery. No stent implantation-related adverse reactions were found in patients undergoing definite intestinal fistula surgery. The average outflow amount of intestinal fluid within 7 days after implantation decreased from (702.7±198.9) ml/d to on the first day after implantation (45.8±22.4) ml/d on the 7th day(F=10.380, P<0.001). The ambulatory time and exercise time of patients continued to increase after stent implantation. The average tolerated exercise time within 14 days after stent implantation increased from (9.1±3.8) min/d to (106.9±21.8) min/d (F=41.727, P<0.001). Within 120 days after stent implantation, 15 patients successfully underwent definite surgery for intestinal fistula and reconstruction of abdominal wall. Patients needed a median (IQR) of 3 (2, 5) days to recover enteral nutrition. The average time from stent placement to surgery was (87.2±17.6) days. Two patients died of severe abdominal infection with multiple organ failure. Conclusion: 3D printing fistula stent can significantly and the outflow of intestinal contents and the difficulty of nursing, and help to restore enteral nutrition and rehabilitation exercise as soon as possible in EAF patients with open abdomen.
Abdominal Wall ; Female ; Humans ; Intestinal Fistula/surgery* ; Male ; Printing, Three-Dimensional ; Retrospective Studies ; Stents ; Treatment Outcome

Anal Canal/surgery* ; Humans ; Rectal Fistula/surgery* ; Treatment Outcome

Anal fistula is one of the most common diseases in colorectal and anal surgery. Most of them are formed after the abscess of perianal space reptures. Due to the complexity and diversity of pathological changes, the clinical efficacy of some patients is not optimistic, and there may even be serious surgical complications, including delayed healing of anal fistula or varying degrees of fecal incontinence, which significantly affect the quality of life of patients and even lead to disability. The Working Committee of Clinical Guidelines of Anorectal Physicians Branch of Chinese Medical Association organized some domestic experts to discuss and prepare this expert consensus. It is suggested that comprehensive evaluation of anal fistula, including detailed medical history, physical examination and necessary auxiliary examination should be conducted before treatment. Auxiliary examinations include fistulography, ultrasound, CT or MRI. The purpose of the auxiliary examination is to accurately determine the position of the internal orifice of the anal fistula, the direction of the fistula and its relationship with the anal sphincter. Adenogenic anal fistula needs surgical treatment after diagnosis. The operation methods can be divided into two types: operations breaching sphincter and operations preserving sphincter function. The former includes anal fistulectomy, anal fistulotomy and seton placement; the latter includes ligation of intersphincteric fistula (LIFT), rectal mucosal muscle flap advancement repair, anal fistula laser closure, video-assisted anal fistula treatment, etc. It is suggested to select or combine the application according to the specific condition of patients. Bioabsorbable materials include anal fistula plug and fibrin glue. Due to the characteristics of retaining sphincter function and reusability, it is recommended to be used selectively by qualified and experienced doctors. Proper wound management after anal fistula surgery can reduce the pain of patients, promote healing and reduce the recurrence of anal fistula. Because there is a certain risk of recurrence and fecal incontinence after anal fistula surgery, for some patients with complex condition, repeated operations or impaired anal function, we must be careful when choosing reoperation, and weigh the benefits of patients and the risk of fecal incontinence.
Anal Canal/surgery* ; China ; Consensus ; Fecal Incontinence/prevention & control* ; Humans ; Quality of Life ; Rectal Fistula/surgery* ; Reoperation/adverse effects* ; Treatment Outcome