Fistulous complications of Crohn's disease

The fistulas encountered in Crohn's disease are a frequent complication and may be internal or external. The first type are gut-to-gut, the second gut-to-skin. Of the 47 Crohn's disease patients operated in this series, 13 presented at least one fistula. The series included 4 cases (8.51%) of external and 9 (19.14%) of internal fistula. A complete cure was obtained in 92.3%, the one failure relating to the still incomplete closure of an enterocutaneous fistula treated conservatively. Surgical mortality was nil and morbidity 15.38% (one energy reoperation and one delayed closure of a perineal wound following proctectomy). The present review examines the various types of fistula encountered and their possible treatment.

Early, aggressive management of postoperative oropharyngocutaneous fistulas

Oropharyngocutaneous fistulas remain a serious and potentially lethal complication. Advantages from surgical repair and the use of musculocutaneous flaps have been demonstrated. Timing of the procedure, however, has not been adequately addressed or emphasized. This report presents our experience with early, aggressive management of postoperative orocutaneous fistulas. Patients were reoperated at an average of 12 days after the initial surgery and underwent exploration, debridement of all devitalized tissues, and closure by reelevation of previously used flaps or with additional flaps. All wounds healed without further problem. We conclude that as long as the patient's general condition permits, early, aggressive management of fistulas should be the procedure of choice to reduce hospital stay and costly wound care and to avoid maceration and partial or complete necrosis of flaps and the potential rupture of the carotid artery. Timely radiotherapy can then be delivered, and quality of life can be significantly improved.

The transcranial Doppler appearance of acute carotid artery occlusion

Transcranial Doppler ultrasound is a noninvasive technique of cerebral blood velocity measurement that is being increasingly used to detect untoward hemodynamic changes. In this report, we describe striking transcranial Doppler ultrasound changes occurring in 2 patients after cervical carotid artery occlusion that led to cerebral infarction. These changes consist of the sudden appearance of a Doppler signal of extremely low pulsatility and moderately high velocity in the middle cerebral artery distribution. In 1 patient, this signal was the first sign of carotid occlusion. We suggest that these transcranial Doppler ultrasound changes can provide an early warning of carotid artery compromise.

[Labyrinth fistula in chronic otitis with cholesteatoma]

The authors studied 116 surgically treated patients with labyrinthine fistulae due to cholesteatoma. The fistulae were most commonly localized on the lateral semicircular canal (75%) and much less frequently involved only the oval window area (7%) and the promontory (4%). The multiple fistulae were found in 14% patients. The closed technique was used, while the open technique was adopted only when the ear was deaf preoperatively, in cases of multiple fistulae and associated intracranial complications. The cholesteatoma matrix was not removed from the fistula of the oval window area or the promontory or in the cases of multiple fistulae and large fistulae of the lateral semicircular canal if the cholesteatoma matrix had penetrated into the labyrinth. The fistulae on the lateral semicircular canal were covered by a piece of fascia. Postoperatively deafness occurred only very exceptionally.

Anterior sagittal anorectoplasty for rectovestibular and anovestibular fistula

Rectovestibular (or anovestibular) fistula is the most common form of anorectal anomaly in female infants. In the surgical repair of these malformations, anal transplantation has been in widespread conventional use. Based on the idea of posterior sagittal anorectoplasty, we devised a new approach, anterior sagittal anorectoplasty, in which, in the lithotomy position, the anterior portion of sphincter muscles are cut through a median perineal skin incision and then the rectum is pulled through the center of these muscles to make its opening at the normal position. The operation has been performed in 12 patients with satisfactory results.

Traction retinal detachment due to preretinal proliferation of surface epithelium

A seven-year-old boy sustained severe blunt trauma with globe rupture. After repair of the globe and lensectomy and vitrectomy, a fistula was noted along with epithelial downgrowth on the posterior surface of the cornea. Extensive peripheral preretinal membrane formation resulted in traction retinal detachment. The fistula was excised and the preretinal membranes were removed. Pathologic examination of the membrane revealed it to be composed of surface epithelium. Retinal reattachment was achieved with intravitreal injection of silicone oil. This case illustrates that surface epithelium can proliferate on the inner retina and can lead to tractional retinal detachment.

Arteriodigestive fistula: a complication associated with intraoperative and external beam radiotherapy following surgery for gastric cancer

Intestinal hemorrhage due to arteriodigestive fistula is described to be a rare and serious complication of radiotherapy. Three cases of this type of fistula in gastric cancer patients treated with gastrectomy, intraoperative electron boost (15 Gy), and fractionated external beam irradiation (46 Gy) are reported. Selective angiography is most helpful in the diagnosis and immediate surgery could be lifesaving. An attempt to explain the etiopathogenesis is made.

Successful salvage of an 8-month-old child with an aortoesophageal fistula

Aortoesophageal fistula (AEF) from an impacted esophageal foreign body was first described in 1818 and has been a uniformly fatal condition to this date. We report the salvage of an 8-month-old child with an AEF from ingesting a straight pin. She survived a massive gastrointestinal (GI) bleed and primary esophageal and aortic repairs performed in conjunction with aortic shunting, interposed pleural flap, and a diverting cervical esophagostomy. This represents the first successful outcome of an AEF from a foreign body, many of which have been described in infants and children. History of esophageal foreign body and signal upper GI hemorrhage should mandate aggressive diagnosis and surgical intervention.

Surgical treatment of massive hydrothorax complicating continuous ambulatory peritoneal dialysis

Acute hydrothorax is a well-recognized complication of continuous ambulatory peritoneal dialysis and is often regarded as a contraindication to its use. We report three cases treated by surgical closure of a communication between the peritoneal and pleural cavities enabling CAPD to continue successfully. This is a simple, safe and effective procedure which merits wider use as an alternative to transferring the patient to permanent hemodialysis.

[A case of an aberrant subclavian artery-esophageal fistula due to prolonged nasogastric intubation]

A case of fatal hematemesis due to an aberrant right subclavian artery-esophageal fistula is presented. The patient was a 9-year-old male child with complex congenital heart disease and developed the fistula by prolonged tracheal and nasogastric intubation after Fontan type operation. To avoid this unusual but serious complication, aberrant subclavian artery should be treated surgically before repair of complex cardiac anomaly.

The use of fibrin sealant in cerebrospinal fluid leakage

Cerebrospinal fluid leakage is one of the central problems facing neurosurgeons, both due to its occasional difficulty in management and to the catastrophical significance of ensuing infection. An important tool emerging in the surgical management of CSF leakage is fibrin sealant, the natural coagulation product. Thirteen cases of CSF leakage, due to meningomyelocele, posttraumatic, and secondary to tumor, that were managed surgically with fibrin sealant are presented. Several of the cases were successfully operated upon following failure of conventional surgical techniques. Additional uses of fibrin sealant in neurosurgery are discussed.

Successful management of aortoesophageal fistula due to thoracic aortic aneurysm

Aortoesophageal fistulas due to atherosclerotic thoracic aneurysms are usually fatal, with few reported survivors. We report an aortoesophageal fistula managed successfully in one stage by resection and replacement of the aortic aneurysm with a prosthetic graft and total esophageal resection. Immediate esophageal reconstruction was attained using orthotopic gastric interposition with omentopexy around the prosthetic aortic graft.

[Role of surgical treatment in thoracic empyema with bronchopleural and/or thoracic empyema]

Sixty-nine patients with thoracic empyema treated surgically were experienced from May, 1978 through December, 1990. Thirty-nine cases had bronchopleural and/or thoracic fistula. Thirty-two patients were associated with pulmonary tuberculosis, of whom fourteen had tuberculous empyema and eighteen were sequelae of pulmonary tuberculosis or tuberculous pleurisy. The remainder were postoperative, postpneumonic, and posttraumatic empyemas. Of fourteen patients who developed postoperative bronchopleural fistula, there were ten patients who had lobectomy or pneumonectomy for lung cancers. Omental pedicle flap method, in which empyema space was filled with the omentum and pedicled muscle flap, was performed on 19 patients with bronchopleural or thoracic fistula or both. Fifteen patients were cured successfully by single-stage procedure, though there was one operative death due to aspiration pneumonia, and two recurrences which were treated by muscle plombages. There was another patient who had multiple surgical procedures in the past resulting in partial recurrences, but the fistula of this patient subsequently closed without reoperation. Postoperative decrease of %VC, FEV1.0/PVC were minimal. Treatment of long standing bronchopleural fistula is a difficult problem, and our omental pedicle flap method is relatively simple and safe which can be most suitably applied to those patients in whom other procedures have failed and to those with poor pulmonary functions.

[The thoracoscopic use of the CO2 laser in the combined treatment of pleural empyema]

A new method for treating acute pneumothorax with a bronchopleural fistula was experimentally developed and clinically tested. It is based on thoracoscopic use of CO2 laser radiation. The laser beam energy is employed for evaporation of necrotic tissues in the area of pulmonary destruction, "welding" of the bronchopulmonary fistulae, and general irradiation of the empyema cavity with a defocused beam. Nineteen patients with various disease duration were treated. In 16 patients the bronchial fistulae and the empyema cavity were eliminated and the lung re-expanded. The purulent inflammation in the pleural cavity was acute in these cases.

Effective surgical treatment for mammary duct fistula

Forty-two patients with 43 mammary duct fistulae, including 23 with a history of at least one previous unsuccessful operation, were treated by excision of the involved duct and fistula alone (15 fistulae) or excision of the fistula combined with total duct excision (28 fistulae). The wounds were closed primarily with antibiotic cover. Two patients had a minor wound infection which settled within 1 month of surgery; one patient developed superficial necrosis of the nipple and one patient required a second operation to excise a discharging sinus. No fistula recurrence has been identified after a median follow-up of 2.5 years. Excision of the involved duct and fistula alone, or excision of the fistula combined with total duct excision performed with antibiotic cover, is probably the treatment of choice for mammary duct fistula.

[Bronchopleural fistulas developing after pulmonary resections for lung cancer predisposing factors, management, and prognosis]

During the past 28 years, 55 bronchopleural fistulas (BPFs) have developed after pulmonary resections for 52 primary and 3 recurrent lung cancers at the National Cancer Center Hospital, Tokyo. During the same period, there were 2446 pulmonary resections for primary lung cancer, the incidence of BPF being 2.1%. As an operative mode of initial resections, pneumonectomy (26 cases) was most common, followed by lobectomy (20 cases), bronchoplasty (8 cases), and stump resection for recurrence (1 case). The following predisposing risk factors for BPF development were identified: resection for locally advanced lung cancer (80.8%); residual carcinomatous tissue at the resected end of bronchus or anastomosis line (29.1%); hypoalbuminemia, diabetes, or steroid administration (20%); pre- and postoperative adjuvant therapy (49.1%). Seven cases received no treatment for BPF because of sudden deaths by massive airway bleeding (5 cases), worsening pneumonia (1 case), and spontaneous recovery (1 case). Remaining 48 cases underwent treatment; tube thoracostomy only in 7 cases and surgical interventions in 41 cases, one case of which was lost during rethoracotomy due to vascular rupture. Initial surgical interventions were composed of combinations of the following procedures; direct re-suture of fistula (16 cases); amputation of the stump and re-closure (3 cases); completion pneumonectomy (6 cases); reinforcement and wrapping of fistula (27 cases); thoracoplasty (29 case). Among these 40 surgical repairs, fistula was successfully closed in 11 cases. In 5 cases, the fistula closure could be achieved after subsequent surgical procedures. Direct re-suture was successful only in 4 cases. In spite of various kinds of treatment, overall prognosis was quite poor; 37 cases died of BPF-related complications (67.3% mortality).(ABSTRACT TRUNCATED AT 250 WORDS)

Traumatic sinus of Valsalva fistula

Two rare cases of nonpenetrating trauma-induced fistula from the right sinus of Valsalva to the right heart chambers are reported. Both were diagnosed preoperatively and operated on successfully. A transverse tear was found in the right sinus of Valsalva, just below the right coronary ostium, in both patients. The ragged inlet and a rough fistula tract were noted during operation. The tears were closed with direct sutures or with a Dacron patch. Coronary artery bypass grafting was needed in 1 patient. The results of operation were excellent.

[Sigmoido-uterine fistula of diverticular origin. Review of the literature apropos of a case]

The authors report one case of sigmoid-uterine fistula of diverticular origin with a favorable outcome after an ideal colectomy associated with subtotal hysterectomy. They emphasize the rarity of this complication, due to the resistance of the uterine tissue. Its diagnosis is primarily clinical, and other examinations are required only to establish the etiological diagnosis. Surgery must be curative, ideally in one stage including the treatment of the diverticular disease and that of its gynecological consequences, which may vary according to the local conditions.

Unilateral naso-orbital meningocele and bilateral congenital fistulae of the lacrimal passages

Orbital meningocele is the protrusion of a sac containing cerebrospinal fluid into the orbit, through a defect called cranium bifidum. Although the occipital and frontal basis of the cranial cavity constitute the two most frequent localizations, this pathology may rarely be located in the naso-orbital region. Other developmental anomalies of the eyes may accompany the anomalies of the bony orbit. The case described in the present paper had a right naso-orbital meningocele associated with bilateral fistulae of the lacrimal passages which represents a very rare condition.

Paediatric tracheostomy: persistent tracheo-cutaneous fistula following decannulation

A retrospective analysis of 101 children with tracheostomies, all performed for upper airway obstruction and who were decannulated in a single department, is reported. Persistent tracheo-cutaneous fistula occurred in 43% of patients and this was significantly related to age at tracheostomy and duration of tracheostomy. The operation of tracheo-cutaneous fistula closure is described.

[Cutaneous fistula of hydatid cyst of the liver]

We report a case of liver hydatic cyst fistulised spontaneously at the skin. It is an extremely scarce complication.

Intraoral reconstruction with a microvascular peritoneal flap

The microvascular peritoneal flap offers a new reconstructive option for closure of intraoral defects. The flap is easy to raise, and donor-site morbidity is low. Unlike fascial flaps, in which the raw surface may take weeks to "mucosalize," the peritoneal surface heals primarily. Finally, the rectus muscle effectively covers all forms of mandibular reconstruction, and the reliable skin paddle makes possible the closure of substantial cutaneous defects.

Anterior perineal sinus

Each year we treat several patients with an anterior perineal sinus tract. They do not conform to commonly encountered perineal problems such as pilonidal disease, epidermal cysts, hidradenitis, fistulous abscess, or inflammatory bowel disease. In an effort to improve understanding of the problem and its clinical significance, we reviewed our practice records for the period from 1968 through 1988. Fifty-six patients underwent surgery for an anterior perineal sinus tract. In 31 patients, the clinical and pathologic condition defied classical diagnostic categorization. We have termed these lesions "anterior perineal sinuses." Their clinical characteristics, treatment, and pathologic assessment from the body of this report. Male predominance (87 percent) and midlife presentation (average age, 44 years) characterized this group. Local symptoms were present from several weeks to several years prior to treatment. Local anesthesia (74 percent) and limited surgery (100 percent) resulted in complete healing in all patients (average, 7 weeks). A 15 percent recurrence rate was noted. The pathologic evaluation demonstrated acute and chronic dermal and subcutaneous inflammation. The etiology of this process remains uncertain. Its predominance along the median raphe suggests a congenital midline inclusion disorder.