Surgical creation of lymphocutaneous fistulas for the management of infants with central lymphatic obstruction

PURPOSE

Central lymphatic obstructions are associated with anasarca and high mortality. We hypothesized that opening dilated cutaneous lymphatic channels by creating a lymphocutaneous fistula (LCF) would decompress the lymphatic circulation and improve anasarca.

METHODS

We reviewed all patients that had at least one LCF created between 9/2019 and 12/2022. LCF efficacy was determined by changes in weight, urine/diuresis, ventilation, and clinical status.

RESULTS

We created eleven LCFs in four infants. LCFs initially drained 108 cc/kg/d (IQR68-265 cc/kg/d). Weights significantly decreased after LCF creation (6.9 [IQR6.1-8.1] kg vs. 6.1 [IQR 4.9-7.6] kg, P = 0.042). Ventilatory support decreased significantly in all patients after at least one LCF was created, and 3/4 patients (75%) had significantly lower peak inspiratory pressures (28 [IQR 25-31] cmH2O vs. 22 [IQR 22-24] cmH2O, P = 0.005; 36 [IQR36-38] cmH2O vs. 33 [IQR 33-35] cmH2O, P = 0.002; 36 [IQR 34-47] cmH2O vs. 28 [28-31] cmH2O, P = 0.002). LCFs remained patent for 29d (IQR 16-49d). LCFs contracted over time, and 6/11 (54.5%) were eventually revised. There were no complications. Two patients died from overwhelming disease, one died from unrelated causes, and one remains alive 29 months after their initial LCF.

CONCLUSION

LCFs provide safe and effective temporary lymphatic decompression in patients with central lymphatic obstruction. While LCFs are not a cure, they can serve as a bridge to more definitive therapies or spontaneous lymphatic remodeling.

LEVEL OF EVIDENCE

IV.

Health-seeking experiences of women with obstetric fistula: a qualitative study at two fistula centres in Ghana

OBJECTIVES

The study explored the health-seeking experiences of women with obstetric fistula from the onset of the condition until surgical treatment was obtained. It also describes their interactions with health staff and traditional healers.

DESIGN

Exploratory, descriptive qualitative study.

SETTING

Two secondary-level health facilities in the northern and central regions of Ghana; data collection took place in 2018-2019.

PARTICIPANTS

A purposive sample of 37 women who had experienced fistula resulting from childbirth and were awaiting fistula repair at the two fistula centres in Ghana was obtained.

DATA ANALYSIS

Thematic analysis was used to analyse the data.

RESULTS

Health-seeking experiences and behaviours of women with obstetric fistula were identified. Six major themes were generated: attribution and perceptions of fistula; competing alternatives/multiple sources of care; limited awareness and access to care; financial barriers; psychosocial challenges, and abuse by healers. The results indicate that the health-seeking experiences of women with obstetric fistula were characterised by long delays in care-seeking. The major themes and subthemes are presented with quotes from participants.

CONCLUSION

The women experienced winding pathways of treatment-seeking due to lack of awareness and incorrect attribution. The major barriers to health-seeking included poverty, challenges with transportation and inadequate repair centres. Increased awareness of obstetric fistula and access to repair centres could shorten the suffering women go through while awaiting fistula treatment. Improved awareness of obstetric fistula and establishment of more fistula centres would be beneficial.

Laparoscopic management of combined cholecystogastric and cholecystocolonic fistulae

Cholecystogastric and cholecystocolonic fistulae are rare sequelae of longstanding cholelithiasis and can complicate surgical management. Our case involves a male patient in his early 40s with a history of chronic cholelithiasis who presented to the emergency department with severe abdominal pain. Findings on imaging were consistent with acute calculous cholecystitis. During laparoscopic cholecystectomy, the presence of both cholecystogastric and cholecystocolonic fistulae was discovered. Fistula resection with cholecystectomy in a one-step approach using indocyanine green (ICG) angiography was performed. The patient improved and was discharged 3 days later. Laparoscopic management complemented by ICG angiography is a viable surgical approach in patients with cholecystogastric and cholecystocolonic fistulae.

Uro-symphyseal Fistula: A Systematic Review to Inform a Contemporary, Evidence-based Management Framework

OBJECTIVE

To collate available data via systematic review considering etiology, presentation, and treatment of Uro-Symphyseal Fistula (USF) in order to inform a contemporary management framework.

MATERIALS AND METHODS

A systematic review was performed according to the Cochrane Handbook and registered in PROSPERO (CRD42021232954). MEDLINE and CENTRAL databases were searched for manuscripts considering USF published between 2000 and 2022. Full text manuscripts were reviewed for clinical data. Univariate statistical analysis was performed where possible.

RESULTS

A total of 31 manuscripts, comprising 248 USF cases, met inclusion criteria. Suprapubic pain and difficulty ambulating were common symptoms. MRI confirmed the diagnosis in 95% of cases. Radiotherapy for prostate cancer was the most common predisposing factor (93%). Among these patients, prior endoscopic bladder outlet surgery was common (83%; bladder neck incision/urethral dilatation n = 59, TURP/GLL PVP n = 34). In those with prior prostatic radiation, conservative management failed in 96% of cases. Cystectomy with urinary diversion (86% n = 184) was favored over bladder-sparing techniques (14% (n = 30) after prior radiation. In radiation naïve patients, conservative management failed in 72% of patients, resulting in either open fistula repair with flap (62%) or radical prostatectomy (28%).

CONCLUSION

Prior radiotherapy is a significant risk factor for USF and almost always requires definitive major surgery (debridement, cystectomy, and urinary diversion). On the basis of the findings within this systematic review, we present management principles that may assist clinicians with these complex cases. Further research into pathogenesis, prevention, and optimal treatment approach is required.

Pancreas sparing duodenectomy and aortic reconstruction with custom-made bovine pericardial tubular graft for primary aorto duodenal fistula. Case report

Primary aorto-duodenal fistula (PADF) is a rare life-threatening condition consisting in a direct communication between the abdominal aorta and the gastrointestinal tract without any previous vascular intervention. PADF results most commonly from an abdominal aortic aneurism (AAA) or aortic bacterial/mycotic infection, with the fistula forming between the native aorta and the third or fourth portion of the duodenum. Symptoms are nonspecific and the diagnosis is often delayed after AAA rupture with high rate of morbidity and mortality. We present a case of 69-year-old-male with a history of untreated abdominal aortic aneurysm who came to the attention of the emergency department for Abdominal aortic aneurysm rupture (RAAA). The patient was successfully treated with staged therapy: endovascular aneurysm repair (EVAR) to control hemorrhage rapidly, followed by pancreas sparing duodenectomy and aortic reconstruction with xenopericardial tube grafts. KEY WORDS: Biological graft, Bovine pericardial tubular graft, Primary aorto-duodenal fistula, Pancreas sparing duodenectomy.

Cerebellar Abscess Induced by Cochlear Fistula due to Chronic Suppurative Otitis Media

Cochlear fistulas with cholesteatoma as the primary disease have been reported frequently in the relevant literature. However, there are no reports of cochlear fistula without cholesteatoma due to chronic suppurative otitis media with intracranial complications. We report a case of cochlear fistula due to chronic otitis media that was diagnosed after the onset of a cerebellar abscess. The patient was a 25-year-old man with severe autism. He was admitted to our hospital with otorrhea from his left ear, emesis, and impaired consciousness. Computed tomography (CT) of the head showed left suppurative otitis media, left cerebellar abscess, and brainstem compression due to hydrocephalus. Right extra-ventricular drainage and brain abscess drainage were urgently performed. The next day, foramen magnum decompression and abscess drainage with partial resection of the swollen cerebellum were performed for decompression purposes. He was subsequently treated with antimicrobial therapy, but magnetic resonance imaging of the head showed an increase in the size of the cerebellar abscess. Re-examination of the temporal bone CT scans revealed a bony defect in the left cochlear promontory angle. We assumed that the cochlear fistula was responsible for the otogenic brain abscess. Thus, the patient underwent surgical closure of the cochlear fistula. After the operation, the cerebellar abscess lesion gradually shrank, and his general condition stabilized. Cochlear fistula should be considered in the management of patients with inflammatory middle ear disease associated with otogenic intracranial complications in the middle ear.

Impella Implantation as a Bridge to Surgery for Repair of Aorto-Right Ventricular Fistula Following Prosthetic Valve Endocarditis: A Case Report

For patients with cardiogenic shock, delaying surgery with mechanical circulatory support is reported to yield better outcomes than emergency surgery. We report on an 82-year-old man diagnosed with vertebral osteomyelitis with concomitant infective endocarditis. Chest radiographs revealed a growing abscess, which resulted in an aorto-right ventricular fistula. Providing Impella support allowed for hemodynamic stabilization prior to surgery. The patient had an uneventful postoperative course and reported to be well in a follow-up 1 year later. Impella support can be used as a bridge to surgery for repairing fistulous tract formation in patients in cardiogenic shock.

Iatrogenic Thermal Energy-Induced Distal Ureteric Injury and Its Management by Laparoscopy Ureteroureterostomy

Background and Objectives

Most thermal energy-induced distal ureter injuries are missed intraoperatively as they are caused by delayed ischemia-induced necrosis of the affected part leading to fistula, and a delayed presentation. The injuries of the distal ureter are commonly managed by ureteroneocystostomy, which has long-term complications related to vesico-ureteric reflux (VUR). We present our experience of management of distal ureter injury due to thermal energy by laparoscopy ureteroureterostomy and the role of various methodologies for its diagnosis.

Methods

It is a retrospective, single-center study that was conducted from January 1, 2020 - December, 31 2022.

Results

A total of 8 cases were enrolled in the study. All cases had an uterovaginal fistula (UVF) post-laparoscopic gynecology surgery. The bilateral ureteric injury was observed in 2 cases. The median post-surgery time to diagnose UVF in the study was 10 days. All cases were managed by laparoscopy ureteroureterostomy (LUUS). Six cases underwent immediate surgery after the diagnosis; whereas 2 cases had initial double-J stent placement as treatment, which subsequently failed following which the LUUS was performed. There were not any immediate or long-term complications such as leakage, stenosis, fistula, or any requirement for revision surgery.

Conclusion

The management of thermal energy-induced ureteric injury is exceptional as compared to other types of ureteric injury. Our approach should be toward immediate surgical management rather than a conservative one to avoid long-term complications and sequelae. Iatrogenic lower ureteral injury can be managed successfully by LUUS, maintaining the normal anatomy and physiology of VUR.

Efficacy and Postoperative Outcomes of Laparoscopic Retrosternal Route Creation for the Gastric Conduit: Propensity Score-Matched Comparison to Posterior Mediastinal Reconstruction

BACKGROUND

Retrosternal reconstruction has lower risks for severe postoperative morbidities, such as gastro-tracheal fistula or esophageal hiatal hernia. We have previously reported the laparoscopic retrosternal route creation (LRRC) method, but its safety and efficacy remain unclear.

METHODS

In total, 374 patients with esophageal carcinoma who underwent minimally invasive McKeown esophagectomy in the prone position between 2010 and 2021 were retrospectively reviewed. We performed a propensity score-matched analysis with the simple, nearest-neighbor method and no calipers to compare postoperative outcomes and reconstructed gastric conduit functionality between patients who underwent LRRC and counterparts who underwent posterior mediastinal reconstruction.

RESULTS

After matching, 62 patients were included in the laparoscopic retrosternal group (LR group) or posterior mediastinal group (PM group). No significant differences were observed between the groups, apart from the number of robot-assisted surgeries, the extent of lymph node dissection, and the method of cervical anastomosis. There were no significant differences in the incidence of Clavien-Dindo grade ≥ 2 complications. Gastro-tracheal fistula (n = 1) and esophageal hiatal hernia (n = 2) occurred in the PM group but not in the LR group. There were no differences in the incidence of pulmonary embolism between the groups (5% vs. 5%). The postoperative anastomotic stenosis rate was similar (16% vs. 27%, p = 0.192). Endoscopic findings of reflux esophagitis (modified Los Angeles classification ≥ M) at 1 year after surgery were significantly better in the LR group (p = 0.037).

CONCLUSIONS

LRRC for gastric conduit reconstruction is safe and valuable. It is associated with good reconstructed gastric conduit function.

Barotrauma-Induced Perilymph Fistula: Video Head Impulse Test and High-Resolution Temporal Bones Computed Tomography Role in Evaluation and FollowUp

We report a case of a woman presenting with unilateral right profound hearing loss accompanied by vertigo secondary to barotrauma-induced perilymph fistula during recreational skydiving. Video head impulse test demonstrated a reduced gain in both the right horizontal and right anterior semicircular canals accompanied by frequently gathered overt corrective saccades. High-resolution computed tomography revealed an enlarged vestibular aqueduct on the affected side, a predisposing factor for the development of perilymph fistula. An exploratory tympanotomy was performed during which a perilymph leak was visualized at the round window niche. Temporal fascia patches enforced by absorbable gelatin sponges were applied to both round and oval windows. During post-surgery follow-up, the patient remained free of vestibular symptoms. An audiogram displayed mild improvement in the right ear speech reception threshold, although her hearing remained non-serviceable. The video head impulse test showed a favorable dynamic with a stepwise return to normal gain values in all semicircular canals and the disappearance of overt corrective saccades. This is the first case in which video head impulse test was employed as a valuable diagnostic tool for the evaluation and post-surgery follow-up of vestibular function in a barotrauma-induced perilymph fistula. The demonstration of an enlarged vestibular aqueduct on high-resolution computed tomography and the risk of perilymph fistula recurrence are discussed.

Influence of Lip Revision Surgery on Facial Growth in Patients With A Cleft Lip

Although patients with cleft lip and palate often present with poor maxillary growth because of intrinsic and iatrogenic factors, the surgical influence of lip revision surgery, palatal fistula repair, and pharyngeal flap procedures remains uncertain in contrast to that of primary cleft lip repair and palatoplasty. Therefore, this study aimed to reveal factors inhibiting maxillary growth and inducing later orthognathic surgery. A retrospective analysis was conducted on the data of patients with cleft lip and palate who underwent a series of treatments at Keio University Hospital from 1990 to 2000. We collected data on patient sex, cleft type, number and timing of lip revision surgery, the incidence of palatal fistulae, history of pharyngeal flap procedures, and timing of a repeat bone graft, and reviewed whether these patients underwent orthognathic surgery later in life. Multivariate analysis was conducted using binary logistic regression to extract factors affecting later orthognathic surgery. A total of 52 patients were included in this study. Results showed that revision surgery conducted more than twice was the highest statistically significant predictor of later orthognathic surgery in patients with a cleft lip and palate ( P <0.05, odds ratio=43.3), followed by palatal fistula occurrence after cleft palate repair ( P <0.05, odds ratio=22.3). Therefore, primary surgical procedure is most important for these patients.

Women's sexual activity and experiences following female genital fistula surgery

BACKGROUND

Surgical repair has a transformative impact on the lives of women affected by female genital fistula; however, various physical, social, and economic challenges may persist postrepair and prevent complete reengagement in relationships and communities. Nuanced investigation of these experiences is needed to inform programming that aligns with women's reintegration needs.

AIM

We investigated the sexual activity resumption, experiences, and concerns of women in Uganda during the year following genital fistula repair surgery.

METHODS

Women were recruited from Mulago Hospital between December 2014 and June 2015. We collected data at baseline and 4 times postsurgery about sociodemographic characteristics and physical/psychosocial status; we also assessed sexual interest and satisfaction twice. We performed in-depth interviews with a subset of participants. We analyzed quantitative findings via univariate analyses, and qualitative findings were coded and analyzed thematically.

OUTCOMES

We assessed sexual readiness, fears, and challenges following surgical repair of female genital fistula using quantitative and qualitative measures of sexual activity, pain with sex, sexual interest/disinterest, and sexual satisfaction/dissatisfaction.

RESULTS

Among the 60 participants, 18% were sexually active at baseline, which decreased to 7% postsurgery and increased to 55% at 1 year after repair. Dyspareunia was reported by 27% at baseline and 10% at 1 year; few described leakage during sex or vaginal dryness. Qualitative findings showed wide variance of sexual experiences. Some reported sexual readiness quickly after surgery, and some were not ready after 1 year. For all, fears included fistula recurrence and unwanted pregnancy.

CONCLUSION

These findings suggest that postrepair sexual experiences vary widely and intersect meaningfully with marital and social roles following fistula and repair. In addition to physical repair, ongoing psychosocial support is needed for comprehensive reintegration and the restoration of desired sexuality.

HIGHLIGHTS

Salvage Surgery

The Department of Veterans Affairs Laryngeal Cancer Study propelled the combination of chemotherapy and radiation therapy to the forefront of strategies used for the management of locally advanced laryngeal cancer. The organ preservation rate was 84%. However, over the past 30 years that these approaches have been in place, there have been concerns regarding long-term survival and high failure rates requiring salvage. Furthermore, salvage laryngectomy, if feasible when considering increased morbidity after CRT, is fraught with a higher risk of wound complications including fistula, longer hospitalization, and reduced quality of life.

Triple Layer Oronasal Fistula Repair Using Local Endonasal Flaps: Case Series of Three Patients

Oronasal fistula (ONF) is a common complication encountered after palatoplasty. Repair is indicated when symptoms impact speech and swallowing. In spite of the variety of surgical approaches described to repair these defects, recurrence rates remain high. Traditionally, successful closure is said to be achieved in using a double-layered approach due to the three-dimensional aspect of the defect. The extent of the fistula into the nasal cavity has incited an increased curiosity in using local endonasal flaps. In recent years, endonasal reconstructive procedures have seen increased interest and application, from cranial base defect repairs to orbital reconstruction and beyond. The nasoseptal (NSF) and inferior turbinate flaps (ITF) possess a robust arterial supply and an exceptional reach with excellent results demonstrated in large defect repair. However, the use of these flaps in ONF repair is scarcely discussed in the literature, and their effectiveness is relatively undetermined. In this manuscript, we present a series of three patients who underwent a triple layer ONF closure, with the oral portion incorporating a turn-in mucosal flap plus a local palate rotation flap or greater palatine artery pedicled-rotation flap, and a NSF or an ITF for the nasal portion of the defect.

Ileoanal pouch-related fistulae: A systematic review with meta-analysis on incidence, treatment options and outcomes

BACKGROUND

Ileoanal pouch related fistulae (PRF) are a complication of restorative proctocolectomy often requiring repeated surgical interventions and with a high risk of long-term recurrence and pouch failure.

AIMS

To assess the incidence of PRF and to report on the outcomes of available surgical treatments.

METHODS

A PRISMA-compliant systematic literature search for articles reporting on PRF in patients with inflammatory bowel diseases (IBD) or familial adenomatous polyposis (FAP) from 1985 to 2020.

RESULTS

34 studies comprising 770 patients with PRF after ileal-pouch anal anastomosis (IPAA) were included. Incidence of PRF was 1.5-12%. In IBD patients Crohn's Disease (CD) was responsible for one every four pouch-vaginal fistulae (PVF) (OR 24.7; p=0.001). The overall fistula recurrence was 49.4%; procedure-specific recurrence was: repeat IPAA (OR 42.1; GRADE +); transvaginal repair (OR 52.3; GRADE ++) and transanal ileal pouch advancement flap (OR 56.9; GRADE ++). The overall failure rate was 19%: pouch excision (OR 0.20; GRADE ++); persistence of diverting stoma (OR 0.13; GRADE +) and persistent fistula (OR 0.18; GRADE +).

CONCLUSION

PVFs are more frequent compared to other types of PRF and are often associated to CD; surgical treatment has a risk of 50% recurrence. Repeat IPAA is the best surgical approach with a 42.1% recurrence rate.

Facial canal dehiscence, dural exposure, and labyrinthine fistula in middle ear cholesteatoma and mastoiditis

PURPOSE

To analyze the prevalence and associations of facial canal dehiscence (FCD), dural exposure, and labyrinthine fistula in chronic otitis media (COM) with and without cholesteatoma.

METHODS

This was a retrospective study performed in an academic medical center. Patients who received tympanoplasty with mastoidectomy for COM with and without cholesteatoma were included. The prevalence of FCD, dural exposure, and labyrinthine fistula in COM with and without cholesteatoma (mastoiditis) and their relationships were analyzed.

RESULTS

A total of 189 patients, including 107 (56.6%) females and 82 (43.4%) males, with 191 ears were included. There were 149 cases (78.0%) of cholesteatoma and 42 patients (22.0%) with mastoiditis. FCD was noted in 27.5% of patients with cholesteatoma and 9.5% of patients with mastoiditis. Dural exposure was found in 21 patients (14.1%) with cholesteatoma and 4 patients (9.5%) with mastoiditis. Eleven patients (7.4%) with cholesteatoma and 1 patient (2.4%) with mastoiditis had labyrinthine fistula. Patients with a labyrinthine fistula had nearly a fivefold greater chance (OR = 4.924, 95% CI = 1.355-17.896, p = 0.015) of having FCD than those without a fistula. There was a positive correlation between dural exposure and labyrinthine fistula (P = 0.011, Fisher's exact test).

CONCLUSION

FCD, dural exposure, and labyrinthine fistula are common complications in COM. These complications are more frequently observed in patients with cholesteatoma than in patients with mastoiditis. Surgeons should pay more attention to the treatment of COM.

Choosing the best endoscopic approach for post-bariatric surgical leaks and fistulas: Basic principles and recommendations

Post-surgical leaks and fistulas are the most feared complication of bariatric surgery. They have become more common in clinical practice given the increasing number of these procedures and can be very difficult to treat. These two related conditions must be distinguished and characterized to guide the appropriate treatment. Leak is defined as a transmural defect with communication between the intra and extraluminal compartments, while fistula is defined as an abnormal communication between two epithelialized surfaces. Traditionally, surgical treatment was the preferred approach for leaks and fistulas and was associated with high morbidity with significant mortality rates. However, with the development of novel devices and techniques, endoscopic therapy plays an increasingly essential role in managing these conditions. Early diagnosis and endoscopic therapy initiation after clinical stabilization are crucial to success since clinical success rates are higher for acute leaks and fistulas when compared to late and chronic leaks and fistulas. Several endoscopic techniques are available with different mechanisms of action, including direct closure, covering/diverting or draining. The treatment should be individualized by considering the characteristics of both the patient and the defect. Although there is a lack of high-quality studies to provide standardized treatment algorithms, this narrative review aims to provide a summary of the current scientific evidence and, based on this data and our extensive experience, make recommendations to help choose the best endoscopic approach for the management of post-bariatric surgical leaks and fistulas.

Head and Neck Reconstruction With 2-Stage External Pectoralis Major Myocutaneous Flap Transfer

BACKGROUND

In head and neck surgery cases where skin is severely scarred or adhered to surrounding tissue, reconstruction can be difficult to perform using microsurgical tissue or conventional pedicled pectoralis major myocutaneous flap (PMMF) transfer given the risks, which include damage to major vessels when manipulating scarred skin. For such cases, we perform a 2-stage external PMMF transfer, whereby the PMMF is directly sutured to the defect over the neck skin (without manipulation the hardened skin), and the flap division is then performed secondarily.

METHODS

A total of 30 patients who had histories of radiotherapy (60-70 Gy) and prior neck dissection received the 2-stage external PMMF transfer procedure. Indications for the flaps included pharyngeal fistula closure in 12 patients, reconstruction for mandibular necrosis after radiotherapy in 8 patients, salvage surgery for partial or total necrosis of the free flap in 4 patients, and simultaneous reconstruction after tumor excision in 6 patients. Two patients underwent a second external PMMF transfer from the contralateral side because of postoperative complications, yielding a total of 32 flap transfers.

RESULTS

Twenty-nine flaps showed complete flap survival, whereas 3 had partial necrosis. Other complications, despite complete flap survival, included large fistulas requiring additional surgery for fistula closure (1 patient) and small fistulas that were closed without requiring reoperation (7 patients).

CONCLUSIONS

External PMMF transfer offers a safe, simple, and effective option in cases where free flap surgery is considered difficult or the risks associated with neck manipulation are high.

[The utility of single-incision retrograde surgery for the infection preauricular fistula]

Objective:To investigate the clinical effectiveness of the single-incision retrograde surgery（SIRS） of the infection preauricular fistula. Methods:A retrospective analysis was performed from April 2016 to May 2021. In the observation group, there were 15 cases of infected preauricular fistula using single-incision retrograde surgical excision. Twenty-four infected preauricular fistulas by double-incision surgery（fistula and infection incisions） were selected as the control group. The recurrence rates, wound healing scores, and scar assessment were compared between the two groups. Results:There were no significant differences in recurrence rate and incision healing between groups（P>0.05）, and the preserved fistula in SIRS group were good without infection recurrence. Moreover, The scar score and the surgical wound in SIRS group were better than that in the control group（P<0.05）. Conclusion:The single-incision retrograde surgery is an effective method of treating infected preauricular fistulas with fewer wounds and fewer scars.

[Clinical application of modified fistulectomy in the treatment of congenital pyriform sinus fistula based on segmental anatomy of fistula]

Objective:To discuss the clinical application and significance of the modified piriform fossa fistulectomy based on segmental anatomy of fistula. Methods:The clinical data of 84 patients with CPSF treated by modified pyriform sinus fistulectomy were analyzed retrospectively. The modified piriform fossa fistula resection adopts the fistula anterograde anatomy method to fine dissect the fistula. The operation procedure can be summarized into four parts: retrograde anatomy of recurrent laryngeal nerve, anatomy of external branch of superior laryngeal nerve, anterograde anatomy of fistula and partial thyroidectomy. Results:All 84 patients successfully completed the operation and discharged from the hospital. The operation time was（64.6±20.0） min, the intraoperative bleeding was（19.6±13.0） mL, and the average hospital stay was（6.8±1.1） d. Postoperative infection occurred in 1 case（1.19%）, temporary vocal cord paralysis in 1 case（1.19%）, no bleeding, pharyngeal fistula, dysphagia, permanent vocal cord paralysis and choking cough. The incidence of complications was 2.3%（2/84）. No complications such as permanent vocal cord paralysis and hypothyroidism occurred. Follow up for 57-106（Median 74） months showed no recurrence. Conclusion:A modified procedure based on segmental dissection of the fistula not only simplifies the traditional procedure, but also procedures the specific steps to provide a targeted and precise resection, which provides a proven surgical solution for complete eradication of the lesion and significantly reduces complications and recurrence.

Use of contrast-enhanced ultrasound in preoperative planning before resection of a second branchial cleft fistula

In the head and neck area, a large proportion of clinically relevant fistulas occur in childhood. The present case describes the use of contrast enhanced ultrasound with intraductal administration of the contrast medium for preoperative visualization of the fistula duct in the case of a second brachial cleft fistula. This provided the surgeon with important additional information, such as the detailed course of the fistula and its relation to the large vessels of the neck. The method can help to improve surgical planning, reduce radiation exposure and to avoid imaging under general anesthesia, especially in children.