British Journal of Obstetrics and Gynaecology April, 1977. Vol84. pp 312-313
ILEO-UTERINE FISTULA AS A COMPLICATION OF MYOMECTOMY CASE REPORT BY
H. E. FADEL* Department of Obstetrics and Gynaecology, Rush Presbyterian St Luke’s Medical Centre Chicago, Illinois Summary A patient is described who developed an ileo-uterine fistula after myomectomy. The fistula caused no symptoms and was discovered at hysterosalpingography for infertility.
with no distension, tenderness or masses. On vaginal examination, the uterus was about normal in size, anteverted and slightly irregular, and there was some right adnexal fullness. At hysterosalpingography on 29th October, 1974 contrast medium (ethiodiol) flowed from the uterus into the right tube, and into the ileum (Fig. 1). A barium meal and followthrough examination as well as a barium enema and intravenous pyelogram were normal. Endometrial biopsy revealed secretory endometrium with no evidence of tuberculosis. At laparotomy on the 20th November, 1974, adhesions between small bowel and uterus were divided, and a loop of ileum was found to be densely adherent to the posterior wall of the uterus near the right cornu. A 5 cm segment of this loop of ileum was resected and an end-to-end anastomosis was made. A wedgeshaped section of the uterine wall surrounding the fistulous tract was excised, and the opened uterine cavity was curetted. The defect in the uterus was then closed with interrupted chromic catgut sutures. Filmy adhesions around both tubes were divided and the abdominal incision was closed without drainage. After operation there were no complications and the patient was discharged on the tenth day. Histological examination of the surgical specimen showed acute and chronic inflammation of the excised portions of uterus and ileum. The curetting showed normal late secretory endometrium.
ONLY87 cases of entero-uterine fistula have been reported previously. The patient now described had an ileo-uterine fistula that was discovered incidentally during the investigation of primary infertility. A unique feature of this fistula was that it was an apparent complication of myomectomy. CASEREPORT The patient was 37 years old and was first seen, because of five years of primary infertility, on 11th October, 1974. At CO, insufflation one year previously, the tubes were judged to be patent. At myomectomy seven months previously two fibroids, whichwere thesize of small oranges, were removed; no further details of operative procedure were available. The patient stated that she had been given antibiotics because of a postoperative fever and she was discharged from hospital on the tenth postoperative day. One week later the patient had a further course of antibiotics for fever and pain in the right lower abdomen. The fever settled but slight lower abdominal pain and backache were noted from time to time. The patient had no vaginal discharge and no gastrointestinal or urinary symptoms. She looked healthy and abdominal examination showed a right paramedian scar
* Present
Address: Department of Obstetrics and Gynecology Medical College of Georgia, Augusta, Georgia 30902. 312
ILEO-UTERINE FISTULA AFTER MYOMECTOMY
FIG.1 Hysterosalpingogram showing the dye passing directly from the posterior aspect of the uterus into the ileum.
There were no problems or abnormalities when the patient was seen at six weeks after operation. She subsequently left town and was lost to follow-up. DISCUSSION Danforth and Case (1933) reviewed the literature and found 58 reports of entero-
3 13
uterine fistulae. Since then, 29 more cases have been described (Martin et al, 1956; Franco and Clough, 1956; Turkel and Weingold, 1962; El-Minawi et al, 1972). The fistula usually joins the uterine fundus to the small intestine or sigmoid colon. In rare instances the rectum, caecum, transverse colon or stomach may be involved. Martin et a1 (1956): in their review of 80 entero-uterine fistulae, found that 42 followed obstetric injury, 17 were inflammatory in origin, 9 complicated carcinoma or its treatment by radiotheraphy and 12 followed trauma (mainly criminal abortion). There is n o previous report of a fistula complicating myomectomy. Entero-uterine fistulae may present with foul-smelling vaginal discharge which may be seen to come through the cervix (Martin et al, 1956), or as cyclical rectal bleeding with secondary amenorrhoea (El-Minawi et al, 1972). This present patient only had intermittent lower abdominal pain and complained o infertility. If a fistula is suspected, hysterography as well as barium studies should be done. Most non-malignant fistulae require surgical treatment because they are unlikely to close spontaneously. Resection of the involved segment of the bowel is usually necessary and hysterectomy (rather than closure of the uterine defect after excision of the tract) should be considered in patients not desiring further child-bearing. REFERENCES Danforth, W. C., and Case, J. T. (1933): American Journal of Obstetrics and Gynecology, 25, 300. El-Minawi, M. F., Huessein, M., Younis, S., and Shaaban, A. (1972) : International Journal of Gynaecology and Obstetrics, 10, 76. Franco, F. O., and Clough, D. M. (1956): American Journal of Surgery, 91, 377. Martin, D. H., Hixson, C. H., and Wilson, Jr. E. C. (1956): Obstetrics and Gynecology, I, 466. Turkel, W. V., and Weingold, A. B. (1962): Obstetrics and Gynecology, 20, 792.
ILEO-UTERINE FISTULA AS A COMPLICATION OF MYOMECTOMY CASE REPORT BY
H. E. FADEL* Department of Obstetrics and Gynaecology, Rush Presbyterian St Luke’s Medical Centre Chicago, Illinois Summary A patient is described who developed an ileo-uterine fistula after myomectomy. The fistula caused no symptoms and was discovered at hysterosalpingography for infertility.
with no distension, tenderness or masses. On vaginal examination, the uterus was about normal in size, anteverted and slightly irregular, and there was some right adnexal fullness. At hysterosalpingography on 29th October, 1974 contrast medium (ethiodiol) flowed from the uterus into the right tube, and into the ileum (Fig. 1). A barium meal and followthrough examination as well as a barium enema and intravenous pyelogram were normal. Endometrial biopsy revealed secretory endometrium with no evidence of tuberculosis. At laparotomy on the 20th November, 1974, adhesions between small bowel and uterus were divided, and a loop of ileum was found to be densely adherent to the posterior wall of the uterus near the right cornu. A 5 cm segment of this loop of ileum was resected and an end-to-end anastomosis was made. A wedgeshaped section of the uterine wall surrounding the fistulous tract was excised, and the opened uterine cavity was curetted. The defect in the uterus was then closed with interrupted chromic catgut sutures. Filmy adhesions around both tubes were divided and the abdominal incision was closed without drainage. After operation there were no complications and the patient was discharged on the tenth day. Histological examination of the surgical specimen showed acute and chronic inflammation of the excised portions of uterus and ileum. The curetting showed normal late secretory endometrium.
ONLY87 cases of entero-uterine fistula have been reported previously. The patient now described had an ileo-uterine fistula that was discovered incidentally during the investigation of primary infertility. A unique feature of this fistula was that it was an apparent complication of myomectomy. CASEREPORT The patient was 37 years old and was first seen, because of five years of primary infertility, on 11th October, 1974. At CO, insufflation one year previously, the tubes were judged to be patent. At myomectomy seven months previously two fibroids, whichwere thesize of small oranges, were removed; no further details of operative procedure were available. The patient stated that she had been given antibiotics because of a postoperative fever and she was discharged from hospital on the tenth postoperative day. One week later the patient had a further course of antibiotics for fever and pain in the right lower abdomen. The fever settled but slight lower abdominal pain and backache were noted from time to time. The patient had no vaginal discharge and no gastrointestinal or urinary symptoms. She looked healthy and abdominal examination showed a right paramedian scar
* Present
Address: Department of Obstetrics and Gynecology Medical College of Georgia, Augusta, Georgia 30902. 312
ILEO-UTERINE FISTULA AFTER MYOMECTOMY
FIG.1 Hysterosalpingogram showing the dye passing directly from the posterior aspect of the uterus into the ileum.
There were no problems or abnormalities when the patient was seen at six weeks after operation. She subsequently left town and was lost to follow-up. DISCUSSION Danforth and Case (1933) reviewed the literature and found 58 reports of entero-
3 13
uterine fistulae. Since then, 29 more cases have been described (Martin et al, 1956; Franco and Clough, 1956; Turkel and Weingold, 1962; El-Minawi et al, 1972). The fistula usually joins the uterine fundus to the small intestine or sigmoid colon. In rare instances the rectum, caecum, transverse colon or stomach may be involved. Martin et a1 (1956): in their review of 80 entero-uterine fistulae, found that 42 followed obstetric injury, 17 were inflammatory in origin, 9 complicated carcinoma or its treatment by radiotheraphy and 12 followed trauma (mainly criminal abortion). There is n o previous report of a fistula complicating myomectomy. Entero-uterine fistulae may present with foul-smelling vaginal discharge which may be seen to come through the cervix (Martin et al, 1956), or as cyclical rectal bleeding with secondary amenorrhoea (El-Minawi et al, 1972). This present patient only had intermittent lower abdominal pain and complained o infertility. If a fistula is suspected, hysterography as well as barium studies should be done. Most non-malignant fistulae require surgical treatment because they are unlikely to close spontaneously. Resection of the involved segment of the bowel is usually necessary and hysterectomy (rather than closure of the uterine defect after excision of the tract) should be considered in patients not desiring further child-bearing. REFERENCES Danforth, W. C., and Case, J. T. (1933): American Journal of Obstetrics and Gynecology, 25, 300. El-Minawi, M. F., Huessein, M., Younis, S., and Shaaban, A. (1972) : International Journal of Gynaecology and Obstetrics, 10, 76. Franco, F. O., and Clough, D. M. (1956): American Journal of Surgery, 91, 377. Martin, D. H., Hixson, C. H., and Wilson, Jr. E. C. (1956): Obstetrics and Gynecology, I, 466. Turkel, W. V., and Weingold, A. B. (1962): Obstetrics and Gynecology, 20, 792.
