Congenital lacrimal fistula

Congenital lacrimal fistula is a rare developmental condition. Patients may be asymptomatic or have tearing from the fistula, the eye or both. The clinical features of 60 patients are reviewed, including presenting symptoms, presence of other lacrimal or systemic anomalies and morphology of the fistula. A detailed description is given of the surgical technique utilised in patients whose symptoms warrant surgical intervention. The results of this technique are presented and alternative treatment strategies are discussed. Theories of the aetiology of the condition are reviewed and morphological and histological evidence is presented to support our belief that congenital lacrimal fistulae represent aberrant canaliculi.

Visualization of coronary artery fistula with transesophageal echocardiography

Coronary artery fistulas are relatively uncommon and are usually initially suspected on auscultation of a continuous murmur. Long-term complications include congestive heart failure, endocarditis, ischemia, and atrial arrhythmias. The role of echocardiography in visualization and diagnosis of these fistulas is expanding. We report two cases in which transesophageal echocardiography was used to visualize and better define proximal coronary arteries and coronary artery fistulas.

Axillobifemoral bypass and aortic exclusion for vascular septic lesions: a multicenter retrospective study of 98 cases. French University Association for Research in Surgery

Ninety-eight patients with aortic infection or aortoenteric fistula were treated by axillobifemoral bypasses and aortic exclusion by 22 surgical teams. Early mortality was 24%. Primary patency at two and five years was 62% and 55%, respectively. Actuarial primary patency at two and five years was 82% and 65%, respectively. The actuarial rate of limb salvage at two and five years was 90% and 82%, respectively. Eight aortic stumps ruptured in less than eight months, postoperatively. Two of these ruptures were treated with success. Infection of the axillobifemoral bypasses was observed in seven cases, six of which were treated successfully. Eight patients had axillary complications, all treated successfully without upper limb sequelae. In eight cases, the axillobifemoral bypass was replaced by a thoracic aortic bypass. Early mortality was higher after emergency operation (30%) than after elective operation (14%). Mortality after cure of primary infection (7%) was lower than after secondary infection (27%). The rate of infection in polytetrafluoroethylene axillobifemoral bypass (3%) was lower than in Dacron axillobifemoral bypass (13%). The rate of occlusion of polytetrafluoroethylene axillobifemoral bypass and Dacron axillobifemoral bypass was identical. The rate of occlusion in ringed reinforced grafts was lower (9%) than in the nonreinforced grafts (22%). The rate of occlusion was significantly higher after ablation of graft for occlusive lesions (38%) than after graft for aneurysms (7.9%) (p less than 0.01).

[A case report of successful repair of an aortopulmonary fistula with partial dissection of the pulmonary artery]

We experienced a case of aortopulmonary fistula due to true thoracic aortic aneurysm. Surgical repair was electively performed when we found coexisting pulmonary arterial dissection. Under extracorporeal circulation, dissected flap was excised and the fistula was closed with his own pericardium, and his aortic arch and innominate artery were replaced with a piece of vascular prosthesis. His intra and post operative condition was stable, and postoperative course was uneventful. Prior to this case 13 surgically treated cases had been reported, and 5 had been successful. Among them, only 2 had been electively operated and both successful. Our case is the second case of aortopulmonary fistula associated with pulmonary arterial dissection.

Surgery for hypospadias fistula

The results of 12 years' experience in the surgical treatment of hypospadias fistula are presented. Overall, there was a success rate of approximately 50% for each attempt at surgical closure of a fistula. The chances of success were not significantly influenced by the number of previous surgical procedures. The best results were obtained with fistulae on the shaft of the penis which were closed with mucosal inversion and advancement of a skin flap over the fistula.

Closure of a coronary fistula with a transcatheter implantable coil

Large sized coronary artery fistulas are rare and diagnosed in only 0.05% of adult catheterized patients. Only a minority of these fistulas are operated upon. We describe a percutaneous technique to close a left coronary artery fistula draining into the right atrium in a 30-yr-old male patient. The fistula was closed by implantation of a trefoil coil, inserted through a catheter selectively advanced into the fistula.

Primary aortoduodenal fistula due to septic aortitis

We report the second case of a primary aortoenteric fistula resulting from septic aortitis with a contained aortic leak into the retroperitoneum and finally erosion into the duodenum. An emergency laparotomy revealed a fistula between the third part of the duodenum and a decompressed sac (false aneurysm) arising from a nonaneurysmal, grossly infected pararenal aorta. The purpose of this report is to present this rare case in detail and to review primary aortoenteric fistulas reported in the English language literature. Most fistulas form in association with an abdominal aortic aneurysm and rarely are due to infection. Only 6% of patients presented with the classic triad of abdominal pain, a palpable mass, and gastrointestinal bleeding. Although 29% of patients presented with massive hemorrhage, adequate time usually existed for surgical treatment of these complications. A patient with ill-defined abdominal pain and fever who suddenly develops a palpable abdominal mass should have an emergency ultrasound or CT scan to exclude the possibility of an infected aortic aneurysm or a contained rupture of an infected nonaneurysmal aorta. If the symptoms are associated with bleeding and the patient is hemodynamically stable, emergent endoscopy should also be performed. If a primary aortoenteric fistula or an aortic pseudoaneurysm is confirmed, emergent surgery should be undertaken to avoid rupture into the bowel or retroperitoneum.

Electrocochleography in the diagnosis of perilymphatic fistula: intraoperative observations and assessment of a new diagnostic office procedure

The intraoperative electrocochleogram (ECochG) was investigated during stapedectomy surgery and during cochleostomy surgery. This provided the justification for obtaining recordings with the oval window (OW) or round window (RW) intact and then when there was a definite fistula. It was noteworthy that no ECochG changes occurred on merely opening the OW or RW, but that marked changes occurred on removing perilymph, even by gentle suction. On raising the intrathoracic pressure and replacing the perilymph, the ECochG potentials usually recovered. Based on these intraoperative observations, an office procedure was designed. The subject was asked to raise the intrathoracic pressure on several occasions and changes in the amplitude of the ECochG potential were noted. An increase of over 15 percent in the action potential (AP), with or without a decrease in the negative summating potential (SP) during the period of raised intrathoracic pressure, was used as the diagnostic criteria for a perilymphatic fistula. A decrease in the AP with or without an increase in the negative SP immediately on relaxing after a period of raised intrathoracic pressure was also treated as a positive diagnostic criterion. Seventy-one normal ears were investigated and a positive result was recorded in two ears (false positive rate: 2.8%). Two hundred and six ears, strongly suspected as having a perilymph leak on the basis of the clinical history and vestibular signs have been investigated over the past 4 years. Ninety positive diagnoses have been reached and 46 of these ears have been surgically explored.(ABSTRACT TRUNCATED AT 250 WORDS)

[MRSA pyothorax due to bronchopleural fistula after grafting and pneumonectomy for traumatic aneurysm of the thoracic aorta--a successful treatment by open drainage and omentopexy]

Treatment of postpneumonectomy pyothorax due to bronchopleural fistula (BPF) is troublesome, especially with methicillin-resistant staphylococcus aureus (MRSA) infection. Moreover, in a bypass-grafting case, the management becomes more complicated. We reported a successful treated case of MRSA pyothorax due to BPF after grafting and pneumonectomy. In a 48-year-old woman performed grafting and pneumonectomy for traumatic aneurysm of the thoracic aorta, MRSA pyothorax due to BPF occurred. BPF was successfully closed by fibrin-glueing under bronchofiberscopy. However pyothorax was not improved by thoracic irrigation for a month. Therefore, open pleural drainage underwent. At the same time, bronchial stump and graft surface was covered with the omental pedicle flap. The open wound had become sterile in two months, and the thoracic window was closed three months after the open drainage.

Closed continuous drainage of cerebrospinal fluid via a lumbar subarachnoid catheter for treatment or prevention of cranial/spinal cerebrospinal fluid fistula

One hundred and seven patients who had a lumbar subarachnoid catheter (teflon or silicone) placed for closed continuous cerebrospinal fluid (CSF) drainage between 1983-1991 are presented. Overall, the drain was successful in achieving the desired goal in 101 of 107 (94%) cases. There were no deaths. Five of 107 (5%) patients developed infections including two cases (2%) of meningitis. There were three cases (3%) of overdrainage with temporary neurologic decline, but all recovered. Five of fifteen (33%) teflon catheters required replacement because of occlusion, but only 5 of 92 (5%) silicone catheters required replacement. Transient lumbar nerve root irritation was seen in 15 of 107 (14%) patients treated for a CSF fistula, and all symptoms resolved after drain removal. CSF fistula/pseudomeningocele after spine surgery was cured by CSF drainage in 36 of 39 (92%) cases; there was a 10% incidence of infection (1 wound, 2 discitis, 1 meningitis). CSF fistula after cranial surgery was cured in 22 of 25 (87%) cases; there was 1 case of (4%) infection and 1 case (4%) of overdrainage. A drain was used to augment a tenuous dural closure in 38 patients with 100% success; no infection occurred and there were 2 cases (5%) of overdrainage. Five patients were successfully treated for traumatic CSF rhinorrhea/otorrhea without complications. The silicone catheter appears superior to the teflon catheter; however, both are simple, safe, and efficacious for the treatment or prevention of CSF fistulas.

[Coronary fistulas, their diagnosis and treatment]

Congenital coronary fistulas diagnosed from systolic-diastolic murmurs were detected in 10 patients. They were verified and located by coronarography in six patients between the right coronary artery and right atrium, right ventricle and pulmonary artery; in four patients between the left coronary artery and pulmonary artery and sinus coronarius cordis. In five patients followed marked left-right shunt the fistula was surgically eliminated by a very favourable postoperative course.

Postoperative cerebrospinal-fluid fistula associated with erosion of the dura. Findings after anterior resection of ossification of the posterior longitudinal ligament in the cervical spine

Of twenty-two patients who had had anterior decompression of the spinal canal for ossification of the posterior longitudinal ligament and cervical myelopathy, seven had absence of the dura adjacent to the ossified part of the ligament. The spinal cord and nerve-roots were visible through this defect. Although the arachnoid membrane appeared to be intact and watertight in most patients, a cerebrospinal-fluid fistula developed postoperatively in five, and three had a second operation to repair the defect in the dura. On the basis of this experience, we recommend use of autogenous muscle or fascial dural patches, immediate lumbar subarachnoid shunting, and modification of the usual postoperative regimen, such as limitation of mechanical pulmonary ventilation to the shortest time that is safely possible and use of anti-emetic and antitussive medications to protect the remaining coverings of the spinal cord when the dura is found to be absent adjacent to an ossified portion of the posterior longitudinal ligament in the cervical spine.

Renal autotransplantation in the management of a ureteroarterial fistula: a case report and review of the literature

A 57-year-old woman who had been treated with an indwelling ureteral stent for over a year was admitted with massive gross hematuria caused by a fistula between the left ureter and hypogastric artery. Despite intensive radiographic evaluation, the definitive diagnosis was made only at the time of surgical exploration. Because of radiation-induced retroperitoneal fibrosis, midureteral obstruction, and prior pelvic and abdominal surgery, primary ureteral repair was not possible, and renal autotransplantation was performed. This case illustrates the need to consider the diagnosis of ureteroarterial fistula in patients with massive hematuria who have chronic indwelling stents, and the feasibility of autotransplantation when primary ureteral repair is not feasible.

Aortoenteric fistula 24 years after aortic endarterectomy

Aortoenteric fistula is a well-recognized and potentially catastrophic complication of aortic surgery. It usually follows aortic graft placement and removal of the prosthesis. Extra-anatomic bypass is the treatment generally recommended. The authors report the case of a 74-year-old woman who presented with an aortoenteric fistula 24 years after aortic endarterectomy. The fistula was managed with an anatomically placed Dacron graft. The radiologic findings and approach to management of this uncommon problem are discussed.

Anterior perineal approach and three-flap anoplasty for imperforate anus: optimal reconstruction with minimal destruction

Despite progress in the treatment of imperforate anus, anal stenosis, rectal prolapse, and other late complications may still arise. In 1987, we described the three-flap anoplasty for the treatment of rectal prolapse following pull-through operations. Since 1986, we have performed 14 three-flap anoplasties in combination with an anterior perineal rectal pull-through for primary treatment of imperforate anus. The mean age at definitive repair was 4.4 months (range, 0 to 14 months). Eleven of the 14 primary pull-through procedures could be performed through a perineal approach only. There were no deaths. At a mean follow-up of 24.2 months, none of the patients has developed prolapse, and only one has had a temporary stenosis. Three children are already fully continent, and soiling is absent in 12. All have a good sphincter tone. Although it is too early to evaluate long-term results, it appears that the three-flap anoplasty prevents mucosal prolapse through the interposition of a skin-lined anal canal. Moreover, a combination of this technique with the anterior perineal approach provides an excellent exposure with minimal dissection of the perineal and pelvic musculature and allows for easy and safe pull-through of the rectal pouch, making an abdominal counterincision unnecessary in most cases. It reproduces at the same time a normal anatomy while taking advantage of all existing structures.

[The diagnosis and treatment of hepatopulmonary fistulae of amebic etiology]

The author has analyzed results of treatment of 28 patients with hepato-thoracic complications of amebic abscesses of the liver. Different variations of operative interventions are proposed including the separate (subdiaphragmatic) draining of the cavity of the liver abscess and pleural cavity and in cases of the appearance of bilio-bronchial fistulas--resection of the lung.

Platform pressure test in identification of perilymphatic fistula

In an effort to better define the effectiveness of the use of posturography in the preoperative diagnosis of perilymphatic fistula (PLF), a prospective investigation of the use of platform pressure posturography was performed. Six different protocols used atmospheric pressure change applied to the external auditory canal. Postural sway, monitored as the output parameter, was evaluated relative to its sensitivity and specificity in five different patient groups. Two independent surgeon groups were used to establish the final diagnosis of perilymphatic fistula. Results within a given surgeon group demonstrate varying sensitivity from 53 to 100 percent and specificity from 56 to 89 percent. Results across the two surgeon groups show nonstatistically significant changes in sensitivity and specificity, yet statistically significant differences exist between the surgeon groups for rate of surgery performed given a suspected patient group, and for rate of positive identification of PLF during surgery. We conclude that although the platform pressure test (PPT) shows promise as a test to raise preoperative suspicion for PLF, actual test performance figures cannot be calculated until a more definitive, objective, test is available to confirm the final diagnosis. The variability of selection criteria and diagnosis by surgical observation is too great to draw clear conclusions relative to test performance. Additionally, the use of vestibular rehabilitation techniques is suggested as a presurgical management strategy for a selected group of suspect patients.

[Abnormal postoperative findings in the external ear canal and tympanic membrane and their treatment]

We describe uncommon complications after tympanoplasty affecting the outer auditory canal and the tympanic membrane such as stenosis of the auditory canal, fistulas, lateralization of the tympanic membrane, anulus cholesteatoma and cholesteatoma of the auditory canal. Typical findings are discussed and explained with the aid of illustrations. Treatment and indications for revision are discussed.

Major thoracic surgery during long-term extracorporeal lung assist for treatment of severe adult respiratory distress syndrome (ARDS)

Surgery in patients treated with extracorporeal lung assist (ELA) carries a high risk of life threatening bleeding complications caused by the need for systemic anticoagulation. A case report describing a successful surgical intervention for the repair of a broncho-pleural leakage by thoracotomy during ELA is presented. A newly developed heparin coated extracorporeal system was used in a patient being treated for severe adult respiratory distress syndrome (ARDS) after left sided pneumectomy. The heparin coated system allowed discontinuation of systemic heparinization intraoperatively without coagulation complications related to the extracorporeal system. This procedure was followed by resolution of the ARDS.

Primary aortoenteric fistulas

Aortoenteric fistulas were first reported in 1822. Primary aortoenteric fistulas are uncommon (less than 200 cases reported). Secondary aortoenteric fistulas are a well-recognized complication of prosthetic grafts (incidence from 0.4 to 2.4%). Atherosclerosis, gallstones, foreign bodies, carcinomas, and diverticular disease are the most common etiologies. Diagnosis is difficult with most studies being nondiagnostic. A high incidence of suspicion is required to successfully diagnosis preoperatively. Surgical repair is required for survival of the patients and should consist of the following: 1) primary closure of the intestinal defect, 2) either primary anatomical repair with a prosthetic graft or extra-anatomical vascular reconstruction, depending upon the presence or absence of infection, and 3) treatment with appropriate antibiotics. One of the largest series of primary aortoenteric fistulas from a single institution consisting of three cases secondary to aneurysmal and granulomatous disease is discussed.

"Floating" labyrinth. Pathophysiology and treatment of perilymph fistula

Collapse of the membranous labyrinth of the pars superior is a morphological change observed in 50% of animals with experimentally produced perilymph fistula, although the extent and degree of the collapse may vary greatly. The moderately collapsed membranous labyrinth may drift with CSF and/or perilymph pressure changes and this may stimulate sensory cells of the utricle and/or semicircular canals if the sensory cells are intact and the collapsed wall is in contact with the otolithic membrane and/or cupula. This condition is termed "floating" labyrinth. Caloric irregularity is often observed in electronystagmograms recorded from animals with experimental perilymph fistula. This is also observed in patients with perilymph fistula. Partial destruction of the vestibular organs using argon laser was performed in a patient with perilymph fistula who was incapacitated because of persistent positional vertigo after closure of the oval window fistula. Irradiation of the argon laser beam was directed to the macula utriculi, utriculoampullary nerve and singular nerve. The hearing of the patient was maintained, and vertigo disappeared after laser labyrinthectomy.