ABSTRACT
Personal experience with the treatment cryptogenic complex anal fistulas over the 10-year period from 1993 to 2002 is reported. Such fistulas accounted for 54 out of 255 fistulas observed (21.1%). Accurate anatomo-pathological classification, based on the connections between the fistulas and the sphincter and the musculature of the pelvic floor, is mandatory, as is thorough preoperative evaluation of ano-rectal function and of the risk of faecal incontinence. The surgical strategies used, in relation to the different kinds of complex fistulas treated, are schematically reported. A mixed technique consisting in fistulectomy-fistulotomy with setons was particularly preferred, because of the risk related to immediate dissection of the sphincter, especially when concurrent risk factors are present. As regards the results obtained, the surgical outcome consisted in healing in 49/54 cases (90.7%) as against recurrence or persistence of the fistula in 5/54 (9.3%). Minor complications occurred in 6/54 (11.1%); no major complications were observed and no cases of permanent faecal incontinence were reported. In conclusion, the surgical choice in cases of complex fistulas must lead to definitive, radical treatment of the lesion, at the same time avoiding irreversible anal incontinence due to severe lesions to the sphincter.
Subject(s)
Rectal Fistula/surgery , Adolescent , Adult , Age Factors , Aged , Electromyography , Female , Humans , Male , Middle Aged , Postoperative Complications , Rectal Fistula/complications , Rectal Fistula/diagnosis , Rectal Fistula/diagnostic imaging , Recurrence , Sex Factors , Treatment Outcome , UltrasonographyABSTRACT
The authors report a case of a pancreatic pseudocyst, due to alcoholic chronic pancreatitis, that was transformed into a pseudoaneurysm of the splenic artery as a result of vascular erosion and that manifested itself with massive haematemesis due to spontaneous fistulisation in the stomach. After defining the incidence of the pancreatic disease and of this unusual form of gastric bleeding, particular attention is devoted to the clinical data and to the aetiopathogenic and physiopathological mechanisms involved in the vascular glandular and periglandular damage, outlining the sources and sites of bleeding. The authors go on to discuss the rationale in using imaging techniques, which cannot ignore the haemodynamic conditions of the patient and the conviction that the execution time of a selective coeliac arteriography never represents an unacceptable delay in the management of a life-threatening ruptured pancreatic pseudoaneurysm. This conviction is due both to the therapeutic potential inherent in the method itself and to the greater safety with which the following operation can be performed, owing to the topographical guidance the procedure provides. After a review of the conditions that make the treatment difficult, the authors stress the importance of a certain measure of eclecticism and careful planning to obtain effective and safe results. Only the combined, integrated efforts of the interventional radiologist and the surgeon can ensure rapid stabilisation of the bleeding and the desired improvement in survival.
