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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.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.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-re-lated 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).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. [ABSTRACT FROM AUTHOR]

To test the Pediatric Bleeding Questionnaire's (PBQ) utility for predicting excessive bleeding during elective surgery, we retrospectively evaluated 60 pediatric patients who had been preoperatively investigated for von Willebrand disease. Of 58 patients with bleeding scores (BS) ≤2 (within normal range), 1 hemorrhaged during surgery. Two had a BS of >2 (positive BS); however, neither bled excessively during surgery. The resulting sensitivity, specificity, positive predictive values, and negative predictive values of the PBQ are 0%, 97%, 0%, and 98%, respectively. On the basis of this small sample, we cannot recommend the PBQ for screening in this setting.

Background: Obtaining blood from children for research studies can be difficult, particularly for controls. One solution is to obtain samples during elective surgery; however, consideration must be given to the potential effects of the timing of phlebotomy., Observations: Ten children were recruited and phlebotomy was carried out during a preoperative clinic visit and intraoperatively immediately after the induction of anesthesia but before the start of surgery. CBCs, VWF, and FVIII levels were measured at both time points and no significant differences were seen., Conclusions: This negative result may be beneficial to pediatric research by suggesting that early intraoperative blood collection for controls does not affect the results.

Simultaneous transplantation of the pancreas is an option for diabetic patients undergoing kidney transplantation to attempt to halt progression of diabetic complications, but the additional risk imposed by the procedure is unclear. Our aim was to determine the morbidity attributable to pancreas transplantation during simultaneous pancreas and kidney transplantation. We compared the first posttransplant year of 18 consecutive recipients of combined pancreas and kidney transplantation to 18 consecutive recipients of kidney transplantation alone. All patients received cadaver donor allografts between 1986 and 1989, and had type I diabetes mellitus with chronic renal failure. There were no differences in patient survival (94% both groups) or satisfactory renal allograft function (89% pancreas/kidney group, 83% kidney group) up to 18 months after transplantation. Eighty-eight percent of pancreas allografts were functioning satisfactorily at 18 months. There was a mean (+/- SD) of 1.5 +/- 1.0 acute rejection episodes per patient for the pancreas/kidney group compared to 0.8 +/- 6 for the kidney-only group (P less than 0.02). Cytomegalovirus infection and wound complications were each encountered more often after pancreas/kidney transplantation than kidney transplantation alone, and together with rejection accounted for a difference in days of hospitalization during the first year (71 +/- 34 vs. 27 +/- 13, P less than 0.001). We conclude that simultaneous pancreas transplantation during cadaver donor kidney transplantation accounted for more frequent rejection episodes, CMV infections, and wound complications. These complications resulted in more hospitalization for patients undergoing simultaneous pancreas/kidney transplantation than kidney transplantation alone.

We have studied the histopathologic correlates of a significantly decreased urinary amylase excretion rate (UAER) to determine its reliability in predicting the presence of cellular rejection within pancreas allografts drained via a duodenocystostomy. Significant hypoamylasuria in pancreas allograft recipients was defined as a diminution of greater than 50% in UAER sustained for greater than 36 hr and not associated with a decrease in serum amylase activity. We observed 18 such episodes of hypoamylasuria in 13 of 18 patients receiving pancreas allografts. Pancreaticoduodenal material was obtained during 11 of these episodes, one attempt failed, and for the remaining 6 episodes we obtained 3 renal allograft biopsy specimens. Histopathologic examination of the 14 specimens revealed cellular rejection in 9 (64%), fibrosis in 2 (14%), enzymatic necrosis in 1 (7%), cytomegaloviral pancreatitis in 1 (7%), and no abnormal features in 1 (7%). During these 14 episodes, a genetically identical renal allograft was present for 11 and showed signs of dysfunction in 9; however, the pancreatic histologic features suggested rejection in only 7 of the 9. Thus even the combination of hypoamylasuria and renal dysfunction in recipients of genetically identical organs was not fully reliable in predicting pancreas allograft rejection. In addition, the interval between organ implantation and onset of hypoamylasuria did not predict the histologic diagnosis. As with other solid-organ allografts, biopsy is a useful adjuvant for determining patient management in the presence of organ dysfunction.