Symposium Colonic Diverticular Disease: Colovesical Fistula ~[URRAY T .
PHEILS, M.CHIR.*
DR. GALLAGHER
T h e next topic is vesicocolic fistula due to diverticulitis, which will be discussed by Professor Murray Pheils of Sydney. Professor Pheils. PROFESSOR PHEILS
Mr. Chairman, ladies and gentlemen. Vesicocolic fistula is an important and potentially lethal complication of diverticular disease. As part of a symposium on diverticular disease in Sydney in 1971, we made a retrospective study of 55 cases. 1 (First slide, please.) You will see that it is a disease of the elderly and that it occurs more frequently in the male, unless the uterus, which normally forms an intervening barrier to the condition in the female, has been removed. Pneumaturia is the most frequent symptom, and it may be the first symptom, occurring out of the blue in a patient who has previously had no indication of diverticular disease. This is followed by urinary symptoms. It is interesting that feces in the bladder or urethra occurs relatively rarely, and urine in the rectum occurs only in men who have associated prostatic obstruction. I agree with my American colleagues that the condition should be called "colovesical fistula," not "vesicocolic fistula," because normally the flow is from the colon to the bladder. T h e durations of symptoms in these patients ranged from two weeks to eight years, and the intervals from demonstration of the fistulas to treatment ranged from one * Professorial Surgical Unit, Repatriation General Hospital, Concord, N. S. W., 2139, Australia.
week to five years, so it may be a relatively acute or a chronic condition. T h e diagnosis is confirmed by cystoscopy or barium-enema study, but the fistula is demonstrable by either means only in certain cases. On cystoscopy, it may be possible to see the fistula, particularly if it is done after the patient has had a barium-enema, where you may see the barium coming through into the bladder like toothpaste out of a toothpaste tube. On tile basis of barium-enema studies you may make the diagnosis because the patient has diverticular disease, but if this is the only thing shown, you may have the differential diagnosis of cancer to consider. We looked at the management of these patients. HospitaI deaths occurred in the patients who had a one-stage operation and patients treated conservatively with colostomy only or not treated at all -- these were poor-risk patients, but it is interesting that one of the patients who had colostomy only had had three attempts at resection by a reputable surgeon, so in some of these patients resection can be very difficult. When we looked again at this case material, we decided to look to see whether we could define any guidelines that would enable us to guide our management in the future, and we found that there were three distinct groups of patients. T h e first group included patients who had pericolic abscesses that had ruptured into the bladder; these were patients with sudden onset. T h e y were extremely ill, with high fevers; they had feces in the urine, and they had large fistuIas. Figure 1 shows the sort of condition that is found, and so does the barium-enema study
560 Dis. CoL & Rect. October 1975
18 Number 7
Volume
Volume 18 Number 7
COLOVESlCAL FISTULA
Fit;,. 1. Pericolic abscess rupturing into bladder. (Reproduced with permission from Pheils MT.I)
done after a preliminary colostomy in such a case. We believe that these patients are better treated by three-stage resection. A n initial colostomy allows you to control, but not cure, the urinary infection, and allows you to get the patient in better condition for a resection. Patients in the second group we call "chronic phlegmonous diverticulitis." These patients have large inflammatory masses attached to their bladders. T h e y have recurrent urinary infection, often with quite long histories of this associated with bowel symptoms, and they may have had several courses of antibiotics. Other factors in the differential diagnosis i n these cases are cancer and Crohn's disease. T h e p h l e g m o n may be a sizeable, very adherent, inflammatory mass that is extremely difficult to resect, and you may end up with a large hole in the bladder. We believe, however, that they are better resected at the first operation, if at all possible, because this may be the best opportunity to do it. Some of these patients
56 1
Fro. 2. Pericolic abscesses and phlegmon adherent to bladder. (Reproduced with permission from Pheils MT.1)
Fie. 3. Established vesicocolic fistula. (Reproduced with permission from Pheils MT.i) have been treated by three-stage resection, and it's been found that even after a proximal colostomy, the inflammatory mass had
562
Dis. Col. & Rect. October 1975
PHEILS
Fro. 4. Chronic phlegmonous diverticulitis. (Reproduced with permission from Pheils MT, et al.2)
not subsided, and the operative conditions had not improved. T h e alternative method of managing these cases is the H a r t m a n n procedure, but we have found that the subsequent hook-up operation can be technically difficult, so we prefer to do a resection and anastomosis at the first stage, and cover this with a transverse colostomy. We leave the transverse colostomy until such time as we are sure that all inflammation in the pelvis has subsided. Experience has shown that the longer you leave the transverse colostomy, the less complicated is its closure (Fig. 2). T h e final group comprises those patients described above in whose cases pneumaturia may suddenly have developed. These patients have small vesicocolic fistulas. There may only be one diverticulum with a little inflammatory reaction, which is quite easily dissected off the bladder; these can be treated by a one-stage resection (Fig. 3). This was a barium-enema study of a patient who had phlegmonous diverticulitis. T h e r e you see the strictured and distorted length of colon, which was firmly attached to the bladder, but you don't see, in fact, a fistula. This slide illustrates the pathologic process that goes on with the chronic phlegmonous diverticulitis, mucosa replaced by
granulation tissue, and a chronic phlegamon with a fibroblastic reaction (Fig. 4).2 With this chronic phlegmon you may find micro or macro abscesses, and you may find foreign bodies. In one of these patients we found a lot of melon seeds. Here is a gross specimen of chronic phlegmonous diverticulitis with the inflammatory mass, and again, this thickened muscle, which is characteristic of chronic diverticular disease. This is typical of the third group, which, as I said, will have pneumaturia, chronic urinary infection, and stabilized vesicocolic fistulas. This illustrates the condition you find. T h a t ' s the x-ray, and on this occasion we were able to demonstrate the vesicocolic fstula. This is an air-contrast barium-enema study in which the tract from the colon going into the bladder is shown, and that's the resected specimen. We believe in resection of diverticular disease. It's important to get right down to the top of the rectum, because unless you do that, you do not remove the abnormal muscle segTnent, and you are liable to get recurrent troubles. Our experience with this sort of operation is that there is a very low incidence of recurrent problems. In conclusion, Mr. Chairman, vesicocolic fistula is a potentially lethal condition. Patients will die from chronic urinary infection unless the lesion is treated surgically. We consider that the appropriate surgical treatment is resection. Following the guidelines I described, we have subsequently treated ten additional patients, two in the first group, four in the second, and four in the third group. There's been no mortality in this series, so we consider that these guidelines according to the three groups are worth considering when you are managing vesicocolic or, as it should be called, colovesical, fistula. T h a n k you. References I. Pheils MT: Vesico-colic fistula due to diverticulitis. Aust NZ J Surg 41:237, 1972 2. Pheils MT, Duraiappah B, Newland R e : Chronic phlegmonous diverticulitis. Aust NZ J Surg 42:337, 1973
PHEILS, M.CHIR.*
DR. GALLAGHER
T h e next topic is vesicocolic fistula due to diverticulitis, which will be discussed by Professor Murray Pheils of Sydney. Professor Pheils. PROFESSOR PHEILS
Mr. Chairman, ladies and gentlemen. Vesicocolic fistula is an important and potentially lethal complication of diverticular disease. As part of a symposium on diverticular disease in Sydney in 1971, we made a retrospective study of 55 cases. 1 (First slide, please.) You will see that it is a disease of the elderly and that it occurs more frequently in the male, unless the uterus, which normally forms an intervening barrier to the condition in the female, has been removed. Pneumaturia is the most frequent symptom, and it may be the first symptom, occurring out of the blue in a patient who has previously had no indication of diverticular disease. This is followed by urinary symptoms. It is interesting that feces in the bladder or urethra occurs relatively rarely, and urine in the rectum occurs only in men who have associated prostatic obstruction. I agree with my American colleagues that the condition should be called "colovesical fistula," not "vesicocolic fistula," because normally the flow is from the colon to the bladder. T h e durations of symptoms in these patients ranged from two weeks to eight years, and the intervals from demonstration of the fistulas to treatment ranged from one * Professorial Surgical Unit, Repatriation General Hospital, Concord, N. S. W., 2139, Australia.
week to five years, so it may be a relatively acute or a chronic condition. T h e diagnosis is confirmed by cystoscopy or barium-enema study, but the fistula is demonstrable by either means only in certain cases. On cystoscopy, it may be possible to see the fistula, particularly if it is done after the patient has had a barium-enema, where you may see the barium coming through into the bladder like toothpaste out of a toothpaste tube. On tile basis of barium-enema studies you may make the diagnosis because the patient has diverticular disease, but if this is the only thing shown, you may have the differential diagnosis of cancer to consider. We looked at the management of these patients. HospitaI deaths occurred in the patients who had a one-stage operation and patients treated conservatively with colostomy only or not treated at all -- these were poor-risk patients, but it is interesting that one of the patients who had colostomy only had had three attempts at resection by a reputable surgeon, so in some of these patients resection can be very difficult. When we looked again at this case material, we decided to look to see whether we could define any guidelines that would enable us to guide our management in the future, and we found that there were three distinct groups of patients. T h e first group included patients who had pericolic abscesses that had ruptured into the bladder; these were patients with sudden onset. T h e y were extremely ill, with high fevers; they had feces in the urine, and they had large fistuIas. Figure 1 shows the sort of condition that is found, and so does the barium-enema study
560 Dis. CoL & Rect. October 1975
18 Number 7
Volume
Volume 18 Number 7
COLOVESlCAL FISTULA
Fit;,. 1. Pericolic abscess rupturing into bladder. (Reproduced with permission from Pheils MT.I)
done after a preliminary colostomy in such a case. We believe that these patients are better treated by three-stage resection. A n initial colostomy allows you to control, but not cure, the urinary infection, and allows you to get the patient in better condition for a resection. Patients in the second group we call "chronic phlegmonous diverticulitis." These patients have large inflammatory masses attached to their bladders. T h e y have recurrent urinary infection, often with quite long histories of this associated with bowel symptoms, and they may have had several courses of antibiotics. Other factors in the differential diagnosis i n these cases are cancer and Crohn's disease. T h e p h l e g m o n may be a sizeable, very adherent, inflammatory mass that is extremely difficult to resect, and you may end up with a large hole in the bladder. We believe, however, that they are better resected at the first operation, if at all possible, because this may be the best opportunity to do it. Some of these patients
56 1
Fro. 2. Pericolic abscesses and phlegmon adherent to bladder. (Reproduced with permission from Pheils MT.1)
Fie. 3. Established vesicocolic fistula. (Reproduced with permission from Pheils MT.i) have been treated by three-stage resection, and it's been found that even after a proximal colostomy, the inflammatory mass had
562
Dis. Col. & Rect. October 1975
PHEILS
Fro. 4. Chronic phlegmonous diverticulitis. (Reproduced with permission from Pheils MT, et al.2)
not subsided, and the operative conditions had not improved. T h e alternative method of managing these cases is the H a r t m a n n procedure, but we have found that the subsequent hook-up operation can be technically difficult, so we prefer to do a resection and anastomosis at the first stage, and cover this with a transverse colostomy. We leave the transverse colostomy until such time as we are sure that all inflammation in the pelvis has subsided. Experience has shown that the longer you leave the transverse colostomy, the less complicated is its closure (Fig. 2). T h e final group comprises those patients described above in whose cases pneumaturia may suddenly have developed. These patients have small vesicocolic fistulas. There may only be one diverticulum with a little inflammatory reaction, which is quite easily dissected off the bladder; these can be treated by a one-stage resection (Fig. 3). This was a barium-enema study of a patient who had phlegmonous diverticulitis. T h e r e you see the strictured and distorted length of colon, which was firmly attached to the bladder, but you don't see, in fact, a fistula. This slide illustrates the pathologic process that goes on with the chronic phlegmonous diverticulitis, mucosa replaced by
granulation tissue, and a chronic phlegamon with a fibroblastic reaction (Fig. 4).2 With this chronic phlegmon you may find micro or macro abscesses, and you may find foreign bodies. In one of these patients we found a lot of melon seeds. Here is a gross specimen of chronic phlegmonous diverticulitis with the inflammatory mass, and again, this thickened muscle, which is characteristic of chronic diverticular disease. This is typical of the third group, which, as I said, will have pneumaturia, chronic urinary infection, and stabilized vesicocolic fistulas. This illustrates the condition you find. T h a t ' s the x-ray, and on this occasion we were able to demonstrate the vesicocolic fstula. This is an air-contrast barium-enema study in which the tract from the colon going into the bladder is shown, and that's the resected specimen. We believe in resection of diverticular disease. It's important to get right down to the top of the rectum, because unless you do that, you do not remove the abnormal muscle segTnent, and you are liable to get recurrent troubles. Our experience with this sort of operation is that there is a very low incidence of recurrent problems. In conclusion, Mr. Chairman, vesicocolic fistula is a potentially lethal condition. Patients will die from chronic urinary infection unless the lesion is treated surgically. We consider that the appropriate surgical treatment is resection. Following the guidelines I described, we have subsequently treated ten additional patients, two in the first group, four in the second, and four in the third group. There's been no mortality in this series, so we consider that these guidelines according to the three groups are worth considering when you are managing vesicocolic or, as it should be called, colovesical, fistula. T h a n k you. References I. Pheils MT: Vesico-colic fistula due to diverticulitis. Aust NZ J Surg 41:237, 1972 2. Pheils MT, Duraiappah B, Newland R e : Chronic phlegmonous diverticulitis. Aust NZ J Surg 42:337, 1973
