Symposium Colonic Diverticular Disease: One-stage Resection for Colovesical Fistula ALEJANDRO F. CASTRO, M.D.*
barium-enema studies; barium, however, was evident in the sinus tract leading to the posterior wall of the bladder. I now show two slides demonstrating air in the bladder seen on intravenous pyelogram films of two patients. The essence of this presentation is the reason I prefer a one-stage resection and primary anastomosis in the treatment of colovesical fistula: 1) Colovesical fistula is not an acute process, and if there was an abscess, it has drained off into the bladder by the time operation is performed. 2) T h e attachment between the colon and the bladder is anterior to the colon and to the dome (above the trigone) of the bladder. 3) It is possible to elevate the rectum because the inflammatory process does not involve the presacral space. 4) There is sufficient normal bowel both below and above the fistula. 5) Morbidity is lower. 6) Operative mortality is comparable. None of these patients died. The technique 0f the operation involves not only the elevation of the rectum and sigmoid from their attachments, but also the separation of the bladder and colon. Once this has been accomplished, the lesion in the bladder is closed over and the colonic resection performed. A Foley catheter, which has been inserted preoperatively, will remain in place for two weeks. The maxims of a good anastomosis are followed: a good blood supply to the ends of the colon; lack of tension; the use of normal bowel ends; avoidance of twisting or rotation; closure of the rent in the
D~. GALLAGHER Dr. Alejandro Castro, of Washington, D.C., will now discuss one-stage resection for colovesical fistula. Dr. Castro. DR. CASTRO Dr. Gallagher, members and guests, these remarks will appear to you as a continuation of those Professor Pheits has made, as some of my slides are very similar to his. The series I am presenting to you is based on 14 patients with colovesical fistulas that I have treated in the last 8 years. I have eliminated three of these patients because cancer was found at operation, although they had been diagnosed preoperatively as having diverticulitis. A slide is presented to show the number of stages used in the surgical correction of this problem. Two patients were subjected to three-stage resection, three were treated by two-stage resection, and the other six (the most recent) had one-stage resection. I would like to bring out that in many instances, symptoms of diverticulitis have been minimal until the onset of pneumaturia has been noticed by the patient. It was interesting that the intervals from onset of pneumaturia to operation for correction of the colovesical fistula averaged two to three months. In no case was barium introduced into the lumen of the bladder in the * 11125 Rockville Maryland 20852.
Pike,
# 308,
Rockville,
563
564
CASTRO
mesentery. T h e suture materials I prefer in a d o u b l e - l a y e r anastomosis are 000 continuous chromic catgut for the mucosa a n d i n t e r r u p t e d 5-0 steel m o n o f i l a m e n t wire for the seromuscular coats. The complications e n c o u n t e r e d posto p e r a t i v e l y were as follows. I n the two patients subjected to three-stage procedures, u r i n a r y infection continued, with cystitis, urethritis, and occasionally, a rare recurrence of p n e u m a t u r i a in one case. I n the three cases in which the two-stage o p e r a t i o n was used, ileus was a p r o b l e m in one case, and in the same patient, a p r o l o n g e d purulent discharge from the d r a i n site used was noticed for several weeks following the i n i t i a l procedure. T h e r e c u r r e n t or continui n g u r i n a r y tract infection, as well as the p r o l o n g e d drainage from the a b d o m i n a l wound, was a t t r i b u t e d to the c o l u m n of
Dis. Col. & Rect.
October 1975
stool r e m a i n i n g in the left colon in spite of the transverse colostomy used as the first stage. C o m p l i c a t i o n s following the one-stage resection were: transient ileus in three cases; a b d o m i n a l - w a l l abscess in one case; a ventral h e r n i a in one case. A b o u t half of the p a t i e n t s in this series were chronic users of alcohol in m o r e t h a n " n o r m a l " quantities. It is, perhaps, this that m a y have caused neglect of the symptom of p n e u m a t u r i a on the p a r t of the patients. I n conclusion, for cure of colovesical fistula caused by d i v e r t i c u l a r disease of the colon, a one-stage resection is desirable a n d recommended. T h a n k you for y o u r a t t e n t i o n a n d the o p p o r t u n i t y to p r e s e n t m y views on this interesting topic.
Memoir TUCKER, CLAUDE C., Springfield, Missouri; born 1882; graduated from medical school in Kansas City in 1909; internship, Metropolitan Hospital, New York City; served with U.S. Armed Forces during World W a r I. Dr. Tucker was a Fellow of the American Society of Colon and Rectal Surgeons, and served as Vice President, 1946-47. He was certified by the American Board of Surgery, a member of the American Medical Association, American Medical Writers Association, Kansas State Medical Society, Sedgwick County Medical Society and founder of the Midwest Poctologic Society. Dr. Tucker practiced in Wichita, Kansas, until his retirement in 1958. He died April 3,1975.
barium-enema studies; barium, however, was evident in the sinus tract leading to the posterior wall of the bladder. I now show two slides demonstrating air in the bladder seen on intravenous pyelogram films of two patients. The essence of this presentation is the reason I prefer a one-stage resection and primary anastomosis in the treatment of colovesical fistula: 1) Colovesical fistula is not an acute process, and if there was an abscess, it has drained off into the bladder by the time operation is performed. 2) T h e attachment between the colon and the bladder is anterior to the colon and to the dome (above the trigone) of the bladder. 3) It is possible to elevate the rectum because the inflammatory process does not involve the presacral space. 4) There is sufficient normal bowel both below and above the fistula. 5) Morbidity is lower. 6) Operative mortality is comparable. None of these patients died. The technique 0f the operation involves not only the elevation of the rectum and sigmoid from their attachments, but also the separation of the bladder and colon. Once this has been accomplished, the lesion in the bladder is closed over and the colonic resection performed. A Foley catheter, which has been inserted preoperatively, will remain in place for two weeks. The maxims of a good anastomosis are followed: a good blood supply to the ends of the colon; lack of tension; the use of normal bowel ends; avoidance of twisting or rotation; closure of the rent in the
D~. GALLAGHER Dr. Alejandro Castro, of Washington, D.C., will now discuss one-stage resection for colovesical fistula. Dr. Castro. DR. CASTRO Dr. Gallagher, members and guests, these remarks will appear to you as a continuation of those Professor Pheits has made, as some of my slides are very similar to his. The series I am presenting to you is based on 14 patients with colovesical fistulas that I have treated in the last 8 years. I have eliminated three of these patients because cancer was found at operation, although they had been diagnosed preoperatively as having diverticulitis. A slide is presented to show the number of stages used in the surgical correction of this problem. Two patients were subjected to three-stage resection, three were treated by two-stage resection, and the other six (the most recent) had one-stage resection. I would like to bring out that in many instances, symptoms of diverticulitis have been minimal until the onset of pneumaturia has been noticed by the patient. It was interesting that the intervals from onset of pneumaturia to operation for correction of the colovesical fistula averaged two to three months. In no case was barium introduced into the lumen of the bladder in the * 11125 Rockville Maryland 20852.
Pike,
# 308,
Rockville,
563
564
CASTRO
mesentery. T h e suture materials I prefer in a d o u b l e - l a y e r anastomosis are 000 continuous chromic catgut for the mucosa a n d i n t e r r u p t e d 5-0 steel m o n o f i l a m e n t wire for the seromuscular coats. The complications e n c o u n t e r e d posto p e r a t i v e l y were as follows. I n the two patients subjected to three-stage procedures, u r i n a r y infection continued, with cystitis, urethritis, and occasionally, a rare recurrence of p n e u m a t u r i a in one case. I n the three cases in which the two-stage o p e r a t i o n was used, ileus was a p r o b l e m in one case, and in the same patient, a p r o l o n g e d purulent discharge from the d r a i n site used was noticed for several weeks following the i n i t i a l procedure. T h e r e c u r r e n t or continui n g u r i n a r y tract infection, as well as the p r o l o n g e d drainage from the a b d o m i n a l wound, was a t t r i b u t e d to the c o l u m n of
Dis. Col. & Rect.
October 1975
stool r e m a i n i n g in the left colon in spite of the transverse colostomy used as the first stage. C o m p l i c a t i o n s following the one-stage resection were: transient ileus in three cases; a b d o m i n a l - w a l l abscess in one case; a ventral h e r n i a in one case. A b o u t half of the p a t i e n t s in this series were chronic users of alcohol in m o r e t h a n " n o r m a l " quantities. It is, perhaps, this that m a y have caused neglect of the symptom of p n e u m a t u r i a on the p a r t of the patients. I n conclusion, for cure of colovesical fistula caused by d i v e r t i c u l a r disease of the colon, a one-stage resection is desirable a n d recommended. T h a n k you for y o u r a t t e n t i o n a n d the o p p o r t u n i t y to p r e s e n t m y views on this interesting topic.
Memoir TUCKER, CLAUDE C., Springfield, Missouri; born 1882; graduated from medical school in Kansas City in 1909; internship, Metropolitan Hospital, New York City; served with U.S. Armed Forces during World W a r I. Dr. Tucker was a Fellow of the American Society of Colon and Rectal Surgeons, and served as Vice President, 1946-47. He was certified by the American Board of Surgery, a member of the American Medical Association, American Medical Writers Association, Kansas State Medical Society, Sedgwick County Medical Society and founder of the Midwest Poctologic Society. Dr. Tucker practiced in Wichita, Kansas, until his retirement in 1958. He died April 3,1975.
