Induction of antitumor activity by immunization with fusions of dendritic and carcinoma cells

Ileosigmoid fistulas are found in Crohn's disease and may present a surgical dilemma. PURPOSE: This study was designed to examine surgical practice to determine types of intervention, enumerate complications, and elicit guidelines for surgical management. METHOD: The medical records of patients with ileosigmoid fistula and Crohn's disease from 1975 to 1995 were reviewed. RESULTS: Ninety patients (44 men) were studied. A preoperative diagnosis of ileosigmoid fistula was made in 77 percent of patients. Sigmoid repair was performed in 43 patients (47.8 percent), sigmoid resection in 32 patients (35.6 percent), 12 patients (13.3 percent) underwent more extensive procedures, and 3 patients (3.3 percent) either had surgery elsewhere or were observed. The fistula was never directly responsible for a stoma. The repair and resection groups were similar with respect to age, length of Crohn's disease, and preoperative symptoms. There was no significant difference between groups in the incidence of postoperative complications; there were no postoperative deaths. Average length of stay was 8.3 days following repair and 9.9 days after resection. Reasons for resection included significant purulence or inflammation, a large fistula defect, a defect on the mesenteric border of the sigmoid, and active sigmoid Crohn's disease. Surgeon's assessment of the presence of Crohn's disease in the sigmoid correlated with pathologic examination and was aided by knowledge of recent endoscopic appearance and biopsy results; intraoperative frozen section and colonoscopy were helpful in distinguishing serosal inflammation from active Crohn's disease. CONCLUSION: Contrast studies identified 77 percent of ileosigmoid fistulas preoperatively. Performing repair rather than resection does not increase the risk of complications, if standard surgical principles are followed. Preoperative or intraoperative endoscopy assists the surgical evaluation of the sigmoid.     

Pelvic and perineal complications of Crohn's disease: assessment using magnetic resonance imaging

This study evaluated the role of magnetic resonance imaging (MRI) in the demonstration of the pelvic and perianal complications of Crohn's disease. Twenty five patients with active Crohn's disease were studied (12 male; mean age 41.1 years). MRI examinations were performed using a 1.5 Tesla system, within 14 days after clinical assessment. T1 and T2 weighted fast spin echo sequences in two or three orthogonal planes were performed, with fat suppression in some cases. The MRI results were correlated with surgical and clinical findings. In 16 patients, cutaneous, deep perineal or enterovesical fistulas or abscesses were diagnosed at MRI which showed close correlation with findings at examination under anaesthetic. In eight patients no fistulas or abscesses were seen at MRI nor was there any evidence of complications on clinical examination and flexible sigmoidoscopy. There was one false negative examination in a patient who had a colovesical fistula. In conclusion, MRI can accurately show the pelvic and perineal complications of Crohn's disease and may render examination under anaesthetic unnecessary.     

Viruses and atherosclerosis: do they play a pathogenic role?

PURPOSE: To evaluate the results of interstitial radiotherapy of anorectal tumors. PATIENTS AND METHODS: From 1972 to 1993, one of the authors treated 45 patients by an interstitial implant for anorectal tumors. Of these, 33 patients suffered from primary tumors, 19 from squamous carcinoma, 2 from basaloid carcinoma of the anus and the other 12 from primary adenocarcinoma of the rectum. Of 12 patients treated for local recurrence, 10 had adenocarcinoma and 2 squamous cell carcinoma. Of the 33 patients with primary tumors, 27 received a course of external-beam radiotherapy before the implant. The median follow-up was 35 months. RESULTS: Local response depended on the tumor volume treated. All 21 anal tumors showed complete response, 5 patients developed local recurrence and 4 distant metastases: 3 died from their disease. Of 12 rectal adenocarcinomas, 9 responded completely, 4 patients developed local recurrence and 4 distant metastases; 6 died from active disease. In the last group of 12 patients who were treated for recurrent tumors, 7 responded completely. One patient developed local recurrence and 9 distant metastases, only 4 are alive. CONCLUSIONS: A combination of external-beam and interstitial radiotherapy is a relatively simple, non-mutilating, but well-tolerated and very effective method of treatment for early carcinoma of the lower rectum and anus.     

Incidence of fistulas after drainage of acute anorectal abscesses

PURPOSE: The aim of this study was to assess the incidence of anal fistulas and factors related to this incidence after incision and drainage of acute cryptoglandular anorectal abscesses. METHODS: Of 170 patients without previous anal fistulas, 146 were followed up for an average of 99 (range, 22-187) months after abscess drainage or until a fistula appeared. RESULTS: Fifty-four (37 percent) patients developed a fistula, and 15 (10 percent) patients developed a recurrent abscess. The incidence of fistulas was higher in females than in males (50 vs. 31 percent; P = 0.0403), especially regarding anterior abscesses (88 vs. 33 percent). Abscesses growing Escherichia coli were more prone to fistula formation than those growing other bacteria (46 vs. 27 percent; P = 0.0368). CONCLUSION: Incision and drainage alone of acute anorectal abscesses is recommended, because an unnecessary primary fistulotomy can be avoided in more than half of the patients by this approach. For superficial anterior abscesses in females, however, primary fistulotomy may be considered.     

Management of acquired rectourinary fistulas: outcome according to cause

PURPOSE: Acquired rectourinary fistulas, an infrequent complication of pelvic conditions, remain a therapeutic problem for which neither a widely accepted classification nor long-term outcome data are available. This study was designed to provide a new etiologic classification system and examine the success of various surgical therapies. It also looked at the need for permanent fecal or urinary diversion or radical excision depending on the cause of the fistula, i.e., benign vs. malignancy-related. METHODS: A retrospective analysis was made of 41 patients treated for acquired rectourinary fistulas between 1980 and 1995. Acquired rectourinary fistulas were classified as 1) benign but caused by Crohn's disease, trauma, perirectal sepsis, or iatrogenic injury; and 2) malignancy-related fistulas secondary to neoplasm, radiation, surgery, or combined tumor and treatment effects. Surgical interventions were classified as repair, excision, fecal diversion, and urinary diversion. RESULTS: Thirty-seven males and 4 females with acquired rectourinary fistula were identified with a mean age of 62 (range, 28-90) years. Nineteen patients had fistulas involving their urethras, and 22 patients had fistulas involving the bladder. Eight patients were not treated surgically; one was not treated because of an advanced malignancy, three because of patient preference, three because of sepsis, and one because of a poor general condition. Of the remaining 33 patients, nine had benign fistulas of which two were the result of Crohn's disease, two were the result of trauma, two were from an iatrogenic response, and three were from perirectal sepsis. Twenty-four patients had malignancy-related fistulas, and five patients had neoplasm at their fistula sites. The remaining 19 patients had malignancy-related fistulas that were the result of cancer treatments. Of the 19 malignancy-related fistulas, 5 were from radiation, 9 were from surgical trauma, and 5 were from radiation and surgical trauma. Forty-nine percent of the patients had undergone attempts at fistula treatment before referral. A resolution of symptoms after initial and reoperative surgery occurred more often in patients with benign fistulas (44 and 100 percent; mean, 1.8 surgeries per patient) compared with malignancy-related fistulas (21 and 88 percent; mean, 2.1 surgeries per patient). The rates of permanent fecal, urinary, and fecal plus urinary diversion were also lower for benign fistulas (11, 0, and 33 percent) compared with malignancy-related fistulas (13, 8, and 54 percent). Permanent diversion was avoided in 56 percent of the benign fistulas but in only 25 percent of the malignancy-related fistulas. The rates of excisional and radical (ileal conduit) surgery were lower for benign fistulas than for malignancy-related fistulas (44 and 11 percent vs. 50 and 54 percent). CONCLUSION: Successful management of rectourinary fistulas typically requires aggressive reoperative therapy with permanent diversion more often required for malignancy-related fistulas. Better outcomes can be anticipated for benign fistulas.     

Does HIV status influence the anatomy of anal fistulas?

PURPOSE: Although anorectal disease is common in human immunodeficiency virus-positive patients, little is known about the type and anatomic distribution of anal fistulas in this patient group. The aim of this study was to compare anatomic characteristics of anal fistulas in human immunodeficiency virus-positive patients with those in human immunodeficiency virus-negative patients by use of a retrospective chart review. METHODS: The charts of 146 male patients younger than 50 years with an anal fistula were reviewed. Incomplete fistulas referred to those tracts arising from an internal opening into either a blind sinus or an undrained abscess cavity. RESULTS: There were 60 human immunodeficiency virus-positive patients and 86 human immunodeficiency virus-negative patients. Mean age of the human immunodeficiency virus-positive patient group was 37 years vs. 40 years for the human immunodeficiency virus-negative patient group. Thirty-one human immunodeficiency virus-positive patients (52 percent) were classified as having AIDS, and the remaining 29 patients (48 percent) were asymptomatic. Mean T helper cell count in the human immunodeficiency virus-positive patient group was 277 cells per microliter. Fistulous tracts were intersphincteric (n = 56), transsphincteric (n = 41), suprasphincteric (n = 2), and incomplete (n = 47). Incomplete fistulas were identified in 33 (55 percent) human immunodeficiency virus-positive patients vs. 14 (16 percent) human immunodeficiency virus-negative patients (P < 0.001). Of the 47 incomplete fistulas, 37 (79 percent) were found in association with an abscess cavity. All ten patients with an incomplete fistula into a blind sinus were human immunodeficiency virus-positive. The incidence of an incomplete fistula without an abscess was significantly higher in the human immunodeficiency virus-positive patient group (17 percent) compared with the human immunodeficiency virus-negative patient group (0 percent; P < 0.001). CONCLUSIONS: Anal fistulas in HIV-positive patients arise from the dentate line in similar locations to human immunodeficiency virus negative patients. However, human immunodeficiency virus-positive patients were more likely to have incomplete anal fistulas than human immunodeficiency virus-negative patients. Furthermore, human immunodeficiency virus-positive patients are predisposed to incomplete fistulas leading into a blind sinus.     

Apoptosis in labial salivary glands from Sj?gren''s syndrome (SS) patients: comparison with human T lymphotropic virus-I (HTLV-I)-seronegative and -seropositive SS patients

Patients with solitary rectal ulcer syndrome (SRUS) frequently present with a mass that can be misinterpreted as cancer. In contrast, the occurrence and characteristics of SRUS-like histopathology produced by underlying malignancy have not been reported in detail. We report seven patients whose rectal mass that was induced by infiltrating carcinoma showed only histopathologic changes of SRUS on initial mucosal biopsy specimens. Carcinoma was evident in subsequent specimens after one to five repeat biopsies with delay in diagnosis from 1 week to 18 months in six patients. In one patient, infiltrating carcinoma was suggested on the first biopsy specimen by immunohistochemistry for cytokeratin. Three of the patients had primary rectal adenocarcinoma, two had metastatic carcinoma from stomach or ovary, and two had direct invasion of anal squamous cell carcinoma or prostatic adenocarcinoma. We conclude that the histopathology of SRUS may occasionally represent a characteristic but nonspecific mucosal reactive change to a deeper seated malignancy. The terminology "solitary rectal ulcer syndrome/mucosal prolapse changes" with a cautionary note may be useful for reporting biopsy results to emphasize the possibility of underlying primary or metastatic malignancy in the differential diagnosis.     

Ultrastructural and immunocytochemical features of a case of neuroendocrine carcinoma developing in a prior ileostomy site

A patient who developed a mixed neuroendocrine carcinoma and adenocarcinoma at the site of a previous long-standing ileostomy is reported. The neuroendocrine features are documented by both ultrastructural and immunocytochemical findings. Carcinoma arising in an ileostomy site is rare but has been recorded in patients with long-standing ileostomies after colectomy for chronic inflammatory bowel disease, as in this patient. Neuroendocrine carcinoma developing in this setting apparently has not been described before, however.     

Ancient gene duplication and differential gene flow in plastid lineages: the GroEL/Cpn60 example

BACKGROUND: The course of Crohn's disease is characterised by the occurrence of intestinal complications such as strictures, intra-abdominal fistulas, or abscesses. Standard diagnostic procedures may fail to show these complications, in particular fistulas. AIMS: To test the value of transabdominal bowel sonography (T) for the detection of intestinal complications in Crohn's disease. METHODS: T was prospectively performed in 213 patients with Crohn's disease in a university based inflammatory bowel disease referral centre. Thirty three underwent resective bowel surgery and were included in this study. The accuracy of T to detect strictures, intra-abdominal fistulas, or abscesses was compared with surgical and pathological findings. RESULTS: T was able to identify strictures in 22/22 patients and to exclude it in 10/11 patients (100% sensitivity, 91% specificity). Fistulas were correctly identified in 20/23 patients and excluded in 9/10 patients (87% sensitivity, 90% specificity). Intra-abdominal abscesses were correctly detected in 9/9 patients and excluded in 22/24 patients (100% sensitivity, 92% specificity). CONCLUSIONS: In experienced hands T is an accurate method for the detection of intestinal complications in Crohn's disease. T is thus recommended as a primary investigative method for evaluation of severe Crohn's disease.     

Anorectal reconstruction by coloperineal anastomosis and dynamic double graciloplasty after abdomino-perineal resection

The aim of this study was to assess the technical and functional results of total anorectal reconstruction with double dynamic graciloplasty after abdominoperineal resection (APR). PATIENTS AND METHODS: From May 1995 to December 1996. 10 patients (6 males and 4 females), with a mean age of 54 years (range 39-74), underwent anorectal reconstruction for low rectal adenocarcinoma. All patients had preoperative radiotherapy and six had postoperative chemotherapy. The surgical procedure was performed in three stages: 1) APR, coloperineal anastomosis, double graciloplasty and ileostomy; 2) three months later, implantation of stimulator and leads; 3) after a two-months training period, the stoma was closed. RESULTS: There was no postoperative mortality. Early and late morbidity occurred in 5 patients: 2 colonic fistulas, 1 necrosis of colon, 1 ileostomy prolapse, 1 neosphincter stenosis, 1 sepsis of stimulator. No patient had recurrence of the disease (mean follow-up 16 months), but two patients died at 3 and 8 months, respectively from anorexia and pulmonary embolism. Seven patients were available for evaluation (2 fistula, 1 death). Before training, the resting pressure and the squeeze pressure were 30 and 175 cm H2O respectively. At the time of evaluation, the electrical stimulated pressure was 95 cm H2O. Six of these 7 patients were continent (5 with spontaneous defecation, 1 with enemas) and 1 was incontinent. CONCLUSIONS: Anorectal reconstruction with dynamic graciloplasty can be an alternative to permanent colostomy for selected patients after APR. However, there is a high morbidity and the quality of life of the patients must be evaluated.     

Cutaneous advancement flap closure: alternative method for treatment of complicated anal fistulas

PURPOSE: A retrospective chart review of 20 consecutive patients with 23 anal fistulas treated with cutaneous advancement flap closure was undertaken to ascertain the efficacy of this previously unreported technique. METHODS: The so-called "diamond" and "house" flaps are commonly used to treat anal stenosis, and mucosal advancement flaps are successfully used to close fistulas. The authors began, in 1994, to close selected fistulas with skin advancement flaps after suture closure of the internal opening and adequate drainage of the external opening. Fourteen patients (4 females; average age, 42 years; a total of 14 fistulas) without inflammatory bowel disease and 6 patients (3 females; average age, 35 years) with inflammatory bowel disease (5 with Crohn's disease; 1 with chronic ulcerative colitis; a total of 8 fistulas) were treated. Indications were low internal opening with transsphincteric fistula in both groups. Mucosal advancement was relatively contraindicated, either because of fear of ectropion or, in the inflammatory bowel disease patients, diseased mucosa. No one in the noninflammatory bowel disease group was diverted or kept without anything by mouth, and all were treated as outpatients or with overnight observation. The inflammatory bowel disease group was either diverted (1 patient) or kept on home total parenteral nutrition (5 patients) for three to six weeks. Cyclosporine, antibiotics, 5-acetylsalicylic acid, and other medications were used judiciously in the inflammatory bowel disease group. RESULTS: In the noninflammatory bowel disease group, complete healing of all wounds occurred in 11 patients in an average of 6.5 weeks (average follow-up, 18 months). Complications included donor site separation in two patients and minor incontinence of flatus in one patient. In the inflammatory bowel disease group, five fistulas healed, two failed, and one patient developed a new fistula during an average follow-up of 16 months. Deep venous thrombosis and catheter sepsis occurred in one patient in this group. There were no fatalities in either group. CONCLUSIONS: Although the numbers, especially in the inflammatory bowel disease group, are very small, the results are encouraging. This technique appears to have a place in the armamentarium of the surgeon repairing anal fistulas.     

Advancement sleeve flaps for treatment of severe perianal Crohn's disease

BACKGROUND: Traditionally proctectomy has been the treatment for severe, complex fistula in ano from Crohn's disease. However, based on the success of rectal advancement flaps in Crohn's disease, circumferential transanal sleeve advancement flaps (TSAFs) were proposed for this subgroup of patients with severe fistula. METHODS: From 1991 to 1995, 13 patients (12 women) with severe perianal Crohn's disease and multiple fistula tracts underwent a TSAF procedure. Data were collected retrospectively using a standard data sheet. RESULTS: There were no postoperative deaths or major morbidity. One year after surgery, the fistula had healed in eight of 13 patients (with three requiring additional surgery before healing). Of patients in whom the procedure failed, three underwent proctectomy for progression of disease and the other two had recurrence of a rectovaginal fistula 6 and 8 months after surgery. Of six variables evaluated (previous procedure, steroid use, steroid dosage, associated Crohn's disease, associated procedures and diverting stoma), only associated procedures were significantly related to a successful outcome (P=0.008). CONCLUSION: Some patients with severe perianal Crohn's fistula and a relatively normal rectum can be offered TSAFs. Even with successful outcome in eight of 13 patients, this may still be a viable option if the only alternative would be total proctocolectomy and a permanent stoma.     

Blockade of mitogen-activated protein kinase cascade signaling in interleukin 6-independent multiple myeloma cells

OBJECTIVE: There have been few studies concerning the clinical pathology of squamous cell carcinoma arising from ovarian mature cystic teratoma. Thus, the objective of this study is to determine clinicopathologic factors affecting survival in this rare tumor. METHODS: From September 1979 to June 1996, 37 patients with squamous cell carcinoma arising from ovarian mature cystic teratoma were treated by the Tokai Ovarian Tumor Study Group. A retrospective clinicopathologic and survival analysis of these patients was performed. The mode of infiltration was classified into expansive, moderately diffused, and diffused patterns. RESULTS: Although the 5-year survival rate was 94.7% and 80.0% for stage I and II patients, respectively, 12 of 13 patients with stage III died within 20 months (P = .0001). A significant difference was also observed between the survival of the groups with and without residual tumor at surgery (P = .0001). Pathologic features, grade, mode of infiltration, and vascular involvement were significant factors by univariate analysis. Multivariate analysis showed significant differences in survival related to grade (P = .0154) and mode of infiltration (P = .0053). The preoperative squamous cell carcinoma antigen level was significantly higher in the patients with squamous cell carcinoma arising from mature cystic teratoma than in patients with mature cystic teratoma (P < .0001). CONCLUSION: This study suggests that pathologic factors, grade, and mode of infiltration can provide valuable information for predicting the survival of patients with squamous cell carcinoma arising from mature cystic teratoma. In addition, squamous cell carcinoma antigen may be a useful marker to detect this disease preoperatively.     

Experience with ambulatory preoperative bowel preparation at the Johns Hopkins Hospital

Ultrasound is in widespread use in the study of gastrointestinal pathologies. In Crohn disease it is helpful in diagnosing complications such as thickening of the bowel loop walls, abscesses, lymph node enlargement and vesical-enteric fistulas. This report presents two cases in which vesical-enteric fistulas were visualized by US; confirming a diagnosis of Crohn's disease in one case, and diagnosing the fistula during the follow-up in the second patient in whom Crohn's disease had previously been diagnosed.     

Malignant esophageal-respiratory fistula and esophageal stenosis treated with a Gianturco-Z-stent

Oesophago-respiratory fistula in most instances in a complication of advanced malignant tumours of the oesophagus or the lung. In our patient group eleven oesophago-respiratory and one gastro-respiratory fistulas were encountered. Three patients were operated upon. In one of them with achalasia, early oesophageal carcinoma was discovered in the background of the fistula. Two patients had fistulas without of oesophageal narrowing, therefore, stent implantation into the trachea and bronchus was performed. One of them was previously managed endoscopically with lyodura plug and fibrin glue, but only temporary occlusion of the fistula was obtained. In five patients, seven conventional oesophageal prosthesis (6 Cook, 1 Rüsch) were used to close the fistulas. In one of these patients, three oesophago-respiratory fistulas developed one after the other at the level of the prosthesis funnel. They were closed with three prostheses connected with short silicone tubes. In the last two patients, Gianturco-Z stent was employed. Its advantages over the plastic prostheses include small basic and lager final luminal diameter, lesser predilatation, easier implantation, lower complication and mortality rate. The silicone coated and double funnel stent with expansile force is effective in fistulas closure. On implantation, stent shortening in minimal, allowing precise placement of the stent even in proximal malignant oesophageal stenosis with oesophago-bronchial fistula. The high price of the stent is compensated for by the lower complication rate, shorter hospitalization and subsequent reduction is hospital expenses. Therefore these metal stents should be financed by the National Health Service, at least in specialized centers for managing patients with dysphagia.     

Relationship between nm23-H1 expression and lymph node metastasis and prognosis in cervical cancer

OBJECTIVE: To investigate the expression of nm23-H1 in cervical carcinoma and its significance. METHODS: Expression of nm23-H1 was examined by immunohistochemical method in 39 cases of adenocarcinoma and 39 cases of squamous cell carcinoma of the uterine cervix. The relationship between expression of nm23-H1 and clinic-pathologic factors and prognosis was analyzed by chi-square test. RESULTS: Positive staining rate of nm23-H1 was 44.6% in adenocarcinoma and 39.2% in squamous cell Carcinoma. The positive staining rate of nm23-H1 in stage I and II adenocarcinoma was 61.1% and 28.6% respectively (P = 0.044); in patients with recurrence nm23-H1 positive rate was lower than that in patients without recurrence (21.5% vs 56%, P = 0.39); in patients with lymph node negative, nm23-H1 positive staining was more than that in patients with lymph node positive (52% vs 28.6%), however, this difference was not statistically significant (P = 0.162). None of 14 cases of lymph node metastasis was strong positive stainig, whereas 7 of 25 without lymph node metastasis were demonstrated to have strong positive staining (P = 0.031). The 5-year survival rate in negative staining group was lower than that in the positive staining group (52.5% vs 82.4%, P = 0.042). In squamous cell carcinoma there was no statistically significant relationship between nm23-H1 expression and clinic-pathologic factors and prognosis. CONCLUSIONS: nm23-H1 expression was associated with biologic behavior in cervical adenocarcinoma.     

Squamous cell carcinoma arising in thyroglossal duct remnant cyst epithelium

The extremely rare occurrence of invasive squamous cell carcinoma arising from normal epithelial lining of a thyroglossal duct remnant cyst is documented by demonstrating the histopathologic transition from normal squamous epithelium to squamous cell carcinoma. The requirements that must be fulfilled to accept a lesion as arising de novo from the epithelial lining are outlined, and all requirements are achieved. The lesion is differentiated from the less rare papillary or papillary-follicular adenocarcinoma of residual thyroid tissue of the thyroglossal duct tract remnants. This is the sixth report in the world literature of invasive squamous cell carcinoma arising from benign thyroglossal remnant squamous epithelium, and the second demonstrating the transition from normal squamous epithelium to invasive squamous cell carcinoma.     

Vesicovaginal and vesicocutaneous fistulas: transurethral suture cystorrhaphy as a new closure technique

PURPOSE: We assessed the usefulness of endoscopic treatment of vesical fistulas. MATERIALS AND METHODS: Two bladder fistula patients underwent transurethral surgery in an attempt to close the fistula. RESULTS: Both patients were cured of the fistula, without undergoing an open procedure. CONCLUSIONS: Cystoscopically assisted suture closure of vesical fistulas can be a successful procedure in selected patients. Nontraditional instrumentation and technique allowed for transurethral closure of these fistulas.     

Synchronous lingual granular cell tumor and squamous carcinoma. A case report and review of the literature

PURPOSE: The aim of this article is to determine the outcome of the pelvic pouch after the occurrence of a fistula. MATERIALS AND METHODS: From 1983 to 1995, 1,040 pelvic pouch surgeries were done at our institution. We reviewed the records of all patients with pouch-related fistulas. Data were collected from chart reviews and our pouch registry. RESULTS: Among 59 patients (22 males) with fistulas, mean age was 33 (range, 19-57) years. Preoperative diagnosis was mucosal ulcerative colitis (n = 52), indeterminate colitis (n = 6), and familial polyposis (n = 1). Site of fistulas included pouch/vaginal (n = 24), pouch/ cutaneous (n = 11), pouch/perineal (n = 16), and pouch/ presacral (n = 8). Postoperative diagnosis was mucosal ulcerative colitis (n = 40), Crohn's disease (n = 14), indeterminate colitis (n = 4), and familial polyposis (n = 1). One hundred eleven (range, 1-7) surgeries for treatment were performed. At a mean follow-up of 26 (range, 1-121) months, 19 pouches (32 percent) had been excised, 34 patients had functioning pouches and no fistula, 5 patients had a closed fistula but refused ileostomy closure, and 1-patient had died of unrelated causes (but the fistula was closed). Pouch type and preoperative diagnosis did not statistically affect pouch failure rates (P = 0.43 and 0.10. respectively). CONCLUSION: Successful treatment of fistula from a pelvic pouch can be achieved in more than 60 percent of patients. However, multiple procedures may be needed for a successful outcome. Ultimately, 32 percent had their pouches excised.     

Microscopic polyangiitis: a case report]

Vertebral osteomyelitis arising from an enteric fistula in patients with inflammatory bowel disease is rare. We report on a patient with Crohn's disease who developed an enteric fistula, resulting in a presacral abscess and vertebral osteomyelitis involving the L4 and L5 vertebral bodies and related disc spaces. This was managed by a defunctioning colostomy with drainage of the pre-sacral abscess. The vertebral lesion was successfully managed non-operatively.