SSAT - SURGICAL MANAGEMENT OF COLOVESICAL FISTULA IN COMPLICATED DIVERTICULAR DISEASE

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SURGICAL MANAGEMENT OF COLOVESICAL FISTULA IN COMPLICATED DIVERTICULAR DISEASE
Thais Reif de Paula^*, Mariane Camargo, Conor P. Delaney, Scott Steele, Hermann Kessler
Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, OH

Fistulas occur in 2% of patients with diverticular disease. Colovesical fistula (CVF) is the most common (65%) type of fistula related to the complicated diverticular disease.
Laparotomy with fistula excision, suture of the bladder wall and resection of the affected segment (generally the sigmoid colon) is the most commonly used procedure. Laparoscopic treatment of CVF has been reported to be as safe with lower overall morbidity and lower complications rate in comparison to open surgery.

Methods
From an IRB approved database, patients were selected using ICD-9 596.1 (CVF) then further selected according to the underlying pathology, diverticular disease. These patients underwent surgical treatment at a single institution, between January 2011 and December 2016. Retrospective analysis of prospectively collected data was carried out in the electronic medical records.
Means for continuous factors and frequencies for categorical are the variables of interest presented.

Outcomes
Of the 61 CVF cases reviewed, 40 had a diverticular disease as underlying pathology (21 male). The mean age was 66.4 ± 11.8 years. The majority of patients had a laparotomy approach (n=22). Eighteen had a laparoscopic procedure and the conversion rate laparoscopic to open was 16.6%. The vast majority had either a sigmoidectomy or a rectosigmoidectomy, and just one patient had a left hemicolectomy. The postoperative complication rate was 25% (8/40). One case of pulmonary embolism (PE) treated with anticoagulation therapy. Three patients presented with increased output ileostomy, evolving with dehydration and prerenal acute kidney injury. None of these had urinary tract injury detected, and all improved with clinical management and vigorous rehydration. One of these three patients also had anemia, treat with two packed red blood cells (PRBC). Anastomotic leak with enterocutaneous fistula complicated one postoperative course, treated with colorectal anastomosis takedown and neo colorectal anastomosis. The same patients also developed dehydration and PE, treated with thrombin inhibitor (post heparin-induced thrombocytopenia). Two patients developed urosepsis, treated with antibiotics. One of these patients had a bladder leak suspected, managed with prolonged foley catheterization. One patient developed a recurrence of CVF and pelvic abscess. He had a CT-guided aspiration and clinical management. Upon failing in resolving symptoms, he underwent an elective redo low anterior resection with colorectal anastomosis and CVF takedown. The median length of stay was 8 days (range 3-25 days).

Conclusion
Resection of the diseased colon segment and primary anastomosis seems to be an effective and safe surgical method for treating CVF. This surgical treatment has an acceptable risk for anastomotic leak. However, the postoperative morbididy is non neglectable.

Surgical management of colovesical fistula in complicated diverticular disease
Variables No (%) of patients
Male 21 (52.5)
Mean age in years (SD) 66.4 ± 11.8
Type of fistula
Colovesical fistula 37 (92.5)
Colovesical + colocutaneous 1 (2.5)
Colovesical + colovaginal 2 (5)
Type of access
Laparoscopic 7 (17.5)
Laparoscopic-assisted 1 (2.5)
Laparoscopic-hand assisted 7 (17.5)
Open 22 (55)
Laparoscopic converted to open 3 (7.5)
Restorative procedure 36 (90)
Hartmann 4 (10)
Diverting loop ileostomy 18 (45)
Bladder treatment
Healing without closure 23 (57.5)
En bloc/ Partial resection and primary suture 3 (7.5)
Primary suture without resection 13 (32.5)
Simple cystectomy with ileal conduit urinary diversion 1 (2.5)
median LOS in days (range) 8 (range 3-25 days).
Complications 8 (20)
Recurrence of colovesical fistula 1 (2.5)

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