B. J. Resio1, J. Reguero Hernandez1 1Yale University School Of Medicine,Surgery,New Haven, CT, USA
Introduction:
It is commonly believed that surgical treatment of colovesical fistula in the elderly carries an increased mortality and morbidity. Thus, patients are often not referred to surgeons for definitive repair and risk undergoing urgent fecal diversion when presenting with urosepsis. The objective of this study was to evaluate current outcomes of colovesical fistula repair in the elderly population with specialized care by colorectal surgeons at an academic tertiary referral hospital and across the country.
Methods:
Consecutive patients age 65 and older who underwent surgery for colovesical fistula were identified from chart review of an academic, tertiary referral hospital (2012-2018) and from the National Surgical Quality Improvement Project (NSQIP) Database (2016). Main outcome measures included surgical approach, complications and mortality. More granular outcomes of permanent ostomy, recurrence, anastomotic leaks, complication type, conversion to open and temporary diverting ostomy were analyzed among patients available for chart review at the tertiary referral hospital.
Results:
A total of 209 elderly patients underwent elective, partial colectomy for vesico-intestinal fistula at NSQIP hospitals in 2016. Fifty-six percent of cases were laparoscopic, complications occurred in 26% of patients and mortality was 2.4%. Eleven elderly patients presented with sepsis, 82% had complications and mortality was 9%.
A total of 21 elderly patients underwent surgery at a single, academic, tertiary referral hospital. Eighteen patients underwent elective surgery, 94% underwent laparoscopic approach, 6% converted to open and 11% underwent a temporary diverting ostomy with primary anastomosis. There was 1 permanent ostomy among the elective group.There were no mortalities, anastomotic leaks or recurrences with a median follow up of 12 months (IQR:4-34). One elderly patient had major complications (arrhythmia, COPD exacerbation, pneumonia) and 22% had minor complications (ileus most common). Three patients presented with urosepsis, underwent urgent diverting colostomy and 2 of 3 were not subsequently reversed (ages 92,96).
Conclusions:
Elderly patients who present with urosepsis from colovesical fistula and require urgent surgery may have a higher risk of permanent ostomy, mortality and complications. Elective repair is safe in the elderly across the country, with a low rate of mortality and morbidity. Chances of permanent ostomy or open approach are low at a tertiary center. Surgical treatment of colovesical fistula should be offered to elderly patients.